Last Name
Geneva Park District Program Registration 710 Western Avenue ~ Geneva , IL 60134 ~ P : 630-232-4542 ~ F : 630-232-4569 ~ genevaparks . org
( Adult ) First Name
Address City State Zip Primary Phone Email Address
Alternate Phone Work Phone
Participants Name Birth Date Age / Grade Program Name Code # Fee
Refunds must be submitted 2 weeks prior to the 1st day of class .
Total Fees
PERSONS WITH SPECIAL NEEDS : The Park District makes reasonable accommodations for persons with special needs to participate . Please specify any adaptive equipment , personnel or other accommodations you need to participate in a program for which you have registered .
Geneva Park District Waiver and Release of All Claims The Geneva Park District ( the “ Park District ) is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard . The Park District continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants ' safety . However , participants and parents / guardians of minors registering for this program / activity must recognize that there is an inherent risk of injury when choosing to participate in recreational activities . You are solely responsible for determining if you or your minor child / ward are physically fit and / or adequately skilled for recreational activities . It is always advisable , especially if the participant is pregnant , disabled in any way or recently suffered an illness , injury or impairment , to consult a physician before undertaking any physical activity .
WARNING OF RISK Recreational activities are intended to challenge and engage the physical , mental and emotional resources of each participant . Despite careful and proper preparation , instruction , medical advice , conditioning and equipment , there is still a risk of serious injury when participating in any recreational activity . Depending on the particular activity , certain risks and dangers may exist due to inclement weather , slips and falls , poor skill level or conditioning , carelessness , horseplay , unsportsmanlike conduct , lack of safety equipment , inadequate or defective equipment , failure in supervision and instruction or officiating , and premises defects . It is impossible for the Park District to guarantee absolute safety .
WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK Please read this form carefully and be aware that in signing up and participating in the Program ( s ), you will be expressly assuming the risk and legal liability and waiving 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 the program ( s )/ activity ( ies ) ( including transportation services , when provided ). I recognize and acknowledge that there are certain risks of physical injury to participants in the program ( s )/ activity ( ies ), and I voluntarily agree to assume the full risk of any injuries , damages or loss , regardless of severity that my minor child / ward or I may sustain as a result of participating in any and all activities connected with or associated with the program ( s )/ activity ( ies ). 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 this program / activity against the Park District , including its officials , agents , volunteers and employees ( hereinafter collectively referred as “ Parties ”). I do hereby fully release and forever discharge the Parties from any and all claims for injuries , damages or loss that my minor child / ward or I may have or which may accrue to me or my minor child / ward and arising out of , connected with , or in any way associated with the program ( s )/ activity ( ies ). I have read and fully understand the above important information , warning of risk , assumption of risk and waiver and release of all claims . If registering on-line or via fax , my on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature . I understand that my child / ward or I may be photographed or videotaped while participating in a Park District program . I give permission for photos and video images of my child / ward or me to be used to promote the Park District ’ s recreation programs . Such photos and video images remain the property of the Park District . PARTICIPATION WILL BE DENIED If the signature of adult participant or parent / guardian and date are not on this waiver . Photo / Video Disclaimer : All participants permit the taking of photos and / or video of themselves and their children during Park District activities , programs , events , and facilities for publication and use as the Park District deems necessary in marketing materials . If you and your child do not wish to be photographed or videotaped , a written objection must be filed with the Park District .
Please indicate your choice of payment :
� Check � Cash � Credit Card
PAYMENT
Card Number
NOTE : Faxed registration must be paid by credit card . 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 .
SIGNATURE
Expiration Date
CVV Code
I have carefully read the Insurance Liability waiver on this form and understand that my signature is required below in order for myself or my child / ward to participate in the Geneva Park District programs . My signature also authorizes payment via the credit / debit card number if provided for payment .
Signature of Participant , Parent or Guardian and Credit / Debit Card Holder if applicable
Date
Office Use Only
Prepared by : Date : Amount : Pmt Method : Copy given to : for : Special Needs Personal Training Priv . Lesson RB / WB League Other _________________
Resident Registration Day August 8 97