Program Registration Form

Upon filling out and SIGNING the following form with your computer please print it out and mail it along with your SIGNED waiver to:New Vision Athletics, PO Box 216, Lake Bluff, IL 60044
OR FAX to: 847-615-0234
If you have any questions please feel free to contact the hotline at 847-295-0682
Family Information:
Family Last Name:
Home Phone: Home Fax:

(Please Note: If you know we already have the below information on file and there have been no changes there is no need to fill out the next part.)

Address: City, State, Zip:

Father's Name & Daytime Phone:
Mother's Name & Daytime Phone:

Alternate Emergency Contact, Relationship, Phone

(If separated of divorced please list spouse or former spouse's information)
Name & Phone:
Address: City, State, Zip:

Check here if you would like us to send a copy of Schedule Information to the above listed individual?
Please select the program you are registering for:
Child's Name Grade School Your Child Attends Birth Date Health Issues - Please List Below Program Description Program Fee

Form of Payment: Payment Terms:
If paying by check please list check number and amount: Check # Amount $ Credit Card: Card #: Exp. Date:

Signature: _________________________________________
Please note that this website is NOT an online commerce site and will not be processing your credit card information. These lines are here simply for your convenience.

Notes / Long Vacation Periods / Requests*
*Please note that requests are primarily for Level 1&2 (kindergarten, 1st & 2nd grades) programs where no scores or standings are kept.
NEW VISION ATHLETICS UNIFORM AGREEMENT

Uniforms are property of New Vision Athletics. Participants have the option to purchase his or her uniform at the season's end for the amount listed below. Failure to return the uniform in the manner set forth below shall be a basis for immediate uniform charge to the credit card number listed below in the amount of $50.

IF YOU DO NOT WISH TO SUPPLY CREDIT CARD INFORMATION AS A DEPOSIT, A SERARATE UNIFORM DEPOSIT CHECK MUST BE PROVIDED FOR THE AMOUNT BELOW.
Checks will be torn up when uniform is returned. Credit cards will not be processed unless the following conditions are not adhered to:
A. Uniform shall be laundered and returned in the same condition as issued.
B. Uniforms shall be returned no later than TWO WEEKS from the conclusion of our Awards Night
C. No names may be added to the jersey. If a name is added, the uniform will be considered a purchase.

I hereby authorize N.V.A. to charge the below listed card for $50 per uniform pertaining to the conditions described above.

Signature: __________________________________________ Date: _____________
Credit Card Number: Expiration Date: