Today's Date:
Child's Name:						Age:
Adult Name:						
# of people (if Family class):
Address:
City:				State:		ZIP:
Are you a Society Member?	Yes____		No____
Home Phone:			Work Phone:
Allergies/Specific Needs:
Class(es) Enrolled in:
Payment:	Cash:____	Check:____	Visa:____	MC:____
TOTAL ENCLOSED: $__________
Card #: ________________________		Exp:___/___/___
Signature:__________________________________

make checks payable to;
Springfield Park District

Mail to
Henson Robinson Zoo Education Department
1100 East Lake Drive
Springfield, IL 62707