LINCOLNWOOD PARKS & RECREATION
REGISTRATION FORM
6900 N. Lincoln Avenue * Lincolnwood, IL 60712
PHONE (847) 677-9740 FAX (847)
673-4413
Visit our Website at www.lincolnwoodil.org
Family Name:___________________________ Payer's Name:_______________________________ Date:___________
Address: _______________________________________City:___________________________ Zip:_______________
Bussiness/Day Phone Number: (____)_______________ Home Phone Number: (____)____________________________
Emergency Phone Number: _________________________ Emergency Name/Relation:____________________________
E-Mail Address:____________________________
Program # |
Program Name |
Participant's Name |
Sex |
Birthdate |
Age |
Current Grade |
Fee |
Does the participant require any assistance or special accommodation to effectively participate and/or enjoy the program? (Please circle) Yes No
If you circled yes, a member of our staff will contact you to make the necessary arragements.
Please indicate your choice of payment: ____Check#____ ____Cash ____Visa ____ Mastercard
(Make Checks Payable to "Village of Lincolnwood")
| NOTE: Only registrations paid by credit card are accepted by FAX. When registering by Fax, it is mutually understood that the facsimile registration documents (including the waiver & release of all claims) shall substitute for and have the same legal effects as the original form. | Expiration Date :____________ Credit Card #:_________________ | |
| Print Name (As it appears on card):_______________________ | ||
| Signature____________________ |
Participant's Waiver, Release And Hold Harmless Agreement |
As participant (or as the parent or guardian of a participant
under age 18) in the Lincolnwood Parks and Recreation Department program(s)
I recognize and acknowlege that there are certain risks of physical injury,
and I agree to assume the full risk of any injury, including death, damage
or loss which I may sustain as a result of participating, in any manner, in
any and all activities associated with the program(s). I also recognize and
acknowledge that all program activities involving strenuous exertion or body
contact are hazardous recreation activities which involve substantial risk
or injury to a participant. Furthur, I understand that this Agreement encompasses
all exercises and physical movements of any nature u ndertaken the program(s),
the use and adjustment of any and all machinery, equipment, apparatus and
anything related to my use of the services, facilities or premises involved
in the program(s) as well as the provision of or failure to provide instructions
or supervision.
I hereby agree to waive and relinquish any and all claims
that I may have, due to participating in the program(s), against the Village
of Lincolnwood, and any and all other participating or cooperating governmental
units, independent contractors, officers, agents, servants and employees of
the governmental units and independent contractors, and any and all other
persons and entities that might be directly or indirectly libabl of any injuries
that I might sustain while participating in the program(s). I hereby fully
release and discharge the Village of Lincolnwood and the above mentioned other
persons and entities from any and all claims for injuries, including death,
damabe or loss that I may have or that may accrue to me because of my participation
in the program(s). I also hereby agree to indemnify, hold harmless and
defend the Village of Lincolnwood and all other persons and entities mentioned
above from any and all claims resulting from injuries, including deathm damages
and loss sustained by anyone, shich arise out of or are in any way associated
with my conduct and activies of the programs(s).
I understand the nature of the program(s) for which I am
registering and have read and fully understand this Waiver, Release and Hold
Harmless Agreement. I further understand and agree that any advertisements
or warning of the particular risks of the program(s) that I subsequently receive
will be incorporated herein by reference and become a part of this Agreeement.
_________________________________________________________ |
___________________ |
| Office use only - Processed by:___________________ Date:_______________ Amount:_______________ |