Activity Guide Spring/Summer 2018 - Page 109

ATHLETIC REGISTRATION FORM PLAYER INFORMATION Participant’s First Name: Participant’s Last Name: Address: City: Home Phone: Zip: Emergency/Cell Phone: Email: Parent’s Full Name: Parent’s Birth Date: Grade During Program: Birth Date: Height: Weight: Male/Female: School Attending: SOCCER ONLY - Requested buddy (please note, you may only request one (1) buddy): 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: VOLUNTEER COACHES INFORMATION Program are dependent on volunteer coaches to be successful. If interested in assisting, please complete the following. Full Name: Email: Please Circle One: Head Coach Assistant Coach REGISTRATION INFORMATION Name of Program: Code Number: Payment Method (Please Circle One): Cash Check Visa Mastercard AMEX Discover Credit Card Number: Card Expires: Signature of Card Holder: Total: $ (icon) CID: PAYMENT PLAN OPTION - READ CAREFULLY: Throughout the guide, this icon is used to indicate that a payment plan is available for a program. If you would like to take advantage of the payment plan option, please check the box below. Your credit card will be charged according to the program’s payment schedule. The schedule for each program varies and can be found on the program’s website or by contacting one of our Registration Offices. By checking this box, I am requesting to sign up for the payment plan option. I understand that my credit card will be charged according to the program’s payment plan schedule. 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, connected with, or in any way associated with these programs and activities. You may return this waiver and release by mail or fax to the address or fax number listed below. It is mutually understood that the facsimile document shall substitute for and have the same legal effect as the original. PHOTO POLICY: The Glen Ellyn Park District reserves the right to photograph or videotape participants in Park District programs, facilities or parks for the District’s promotional use including its electronic media, brochures, flyers and other publications without additional prior notice or permissions and without compensation. Signature (Parent or Guardian): Date: PLEASE RETURN YOUR FORM TO: Via mail to Registration, Glen Ellyn Park District, 185 Spring Avenue, Glen Ellyn, IL 60137 or via fax to (630) 942-8759. 109