Activity Guide Spring/Summer 2018 - Page 108

REGISTRATION FORM Last Name: Home Phone: Work/Emergency Phone: Parent’s Full Name: Parent’s Birth Date: Address: City: Zip: Email: Payment Method (Please Circle One): Cash Check Visa Mastercard Credit Card Number: AMEX Discover Card Expires: CID: Signature of Card Holder: Would You Like to Receive the Glen Ellyn Park District’s eNewsletter (Please Circle One)? CODE NUMBER ACTIVITY NAME FEE Add a donation to the Park District Scholarship Fund! $ TOTAL FEE $ YES PARTICIPANT’S FIRST NAME NO SEX BIRTH DATE The Glen Ellyn Park District makes reasonable accommodations in recreation programs to enable persons with disabilities to participate. Please specify below any adaptive equipment, personnel, or other accomodations you need to participate in a program for which you have registered: WAIVER AND RELEASE OF ALL CLAIMS Please read this section carefully and be aware that in signing up and participating in the above identified programs and activities, you will be expressly assuming the risk and legal liability and availing and releasing all claims for injuries, damages or loss which you or your minor child ward might sustain as a result of participating in any and all activities connected with and associated with said programs/activities (including transportation services, when provided). I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in these programs/activities against the Glen Ellyn Park District, including its officials, agents, volunteers and employees (hereinafter collectively referred as “District”). I do hereby fully release and forever discharge the District from any and all claims or injuries, damages, or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward arising out of, c ۛXY] ܈[[H^H\X]Y]\Hܘ[\˜[X]]Y\ˈ[HX^H]\\Z]\[[X\HHXZ[܈^HY\܈^\\Y[ˈ]\]]X[H[\]HX[Z[H[[X]]H܈[]HH[YHY[YX\HܚY[[ PNH[[[\\X\\\HYܘ\܈Y[\H\X\[[\\Xܘ[\X[]Y\܈\܈H\X8&\[[ۘ[\H[Y[][XۚXYYXK\\Y\[\XX][ۜ]]Y][ۘ[[܂XH܈\Z\[ۜ[]]\[][ۋYۘ]\NL]NPTHUTSTԓH΂XHXZ[Y\][ۋ[[[\\X  N H[][YK[[[S L܈XH^ HM N NK