Rebate Form

First Name: Last Name:

Address:

City: State: Zip:

Phone:

Email Address:

Date:

Be sure to include your receipt and copy of your tax bill or voter's registration card for each rebate request!

District Attended:
Program:	In-District Rate	Out-District Rate	Rebate Amount
Program:	$	$	$
Program:	In-District Rate	Out-District Rate	Rebate Amount
Program:	$	$	$
Program:	In-District Rate	Out-District Rate	Rebate Amount
Program:	$	$	$
Be sure to include your receipt and a copy of your tax bill or voter's registration card !		Total Rebate:	$

Mail To:
Barrington Countryside Park District
| P.O. Box 1393 | Barrington | Illinois | 60011 |

Fax To: (847)783-6772

Barrington Countryside Park District | P.O. Box 1393 | Barrington, Illinois | 60011 | (847)783-6772