Lake Forest Parks & Recreation Brochures Summer & Camp 2019 - Page 80

Seasonal Jobs LAKE FOREST PARKS & RECREATION DEPARTMENT REGISTRATION FORM 400 HASTINGS RD • LAKE FOREST, IL 60045 • 847.234.6700 • FAX: 847.615.4251 Family Name: Date: Address: Home Phone: Cell Phone: Emergency Contact: Phone: Email Address: MEDICAL CONCERNS Please note any diet limitations, allergies, special medications, or additional conditions which may affect participation. Name: Comments: PARTICIPANT’S NAME AGE GRADE BIRTH DATE SEX M OR F ACTIVITY CODE # ACTIVITY NAME BEGINNING DATE FEE $ $ $ $ $ $ TOTAL $ AMERICANS WITH DISABILITIES ACT We encourage participation by everyone and provide reasonable accommodations in accordance with ADA standards. If you require program assistance for special needs, check the box to be contacted by our NSSRA Inclusion Liaison, Joe Mobile. A diagnosis is not necessary. Joe Mobile can also be reached at 847.810.3941 or mobilej@cityoflakeforest.com. YES, please call with information. If you do not hear from us within two weeks prior to the start date of a program, we encourage you to contact the Recreation Department. Please read this form carefully and be aware that by registering for and participating in this program(s), or by registering your minor child/ward for participation in this program(s), you will be waiving your rights and/or the rights of your minor child/ward to all claims for injuries you or your minor child/ward might sustain arising out of this program(s) and you will be required to indemnify, hold harmless, and defend the Lake Forest Recreation Department and the City of Lake Forest for any claims arising out of participation in said program(s). For purposes of this Liability Waiver and Hold Harmless Agreement, the “program” or “programs” to which it relates include any and all activities undertaken or supervised by, or otherwise made available by or through, the Lake Forest Recreation Department and/or The City of Lake Forest (collectively “Lake Forest”), including activities involving the unsupervised use of equipment of property of Lake Forest. Risk of Injury: “As a participant in the program, or as a parent or legal guardian of a participant under 18 years of age, I recognize and acknowledge that there are certain risks of physical injury, and I agree to assume the full risk of injuries, including death, damages, or loss which I may sustain as a result of participating in any and all activities associated with this program, including transportation and approved vehicle operation when provided.” Waiver of Injury Claims: “I agree to waive and relinquish any and all claims I may have arising out of, connected with, or in any way associated with the activities of the program, including transportation and approved vehicle operation when provided.” Release from Liability: “I do hereby fully release and discharge the Lake Forest Recreation Department and the City of Lake Forest and its officers, agents, and employees from any and all claims from injuries, including death, damage or loss which I or my minor child/ward may have or which may occur on account of participation in the program, including transportation and approved vehicle operation when provided.” Indemnity and Defense: “I further agree to indemnify, hold harmless and defend the Lake Forest Recreation Department and the City of Lake Forest and its officers, agents, and employees from any and all claims from injuries, including death, damages and losses sustained by me or my minor child/ward and arising out of, connected with, or in any way associated with the activities of the program, including transportation and approved vehicle operation when provided.” In the event of any emergency, I authorize the Lake Forest Recreation Department to secure from any licensed hospital, physician, and / or medical personnel any treatment deemed reasonable and necessary for my minor child’s immediate care and agree that I will be responsible for payment of any and all medical services rendered.” ATTENTION! PLEASE FILL OUT YOUR REGISTRATION FORM COMPLETELY. DON’T FORGET TO SIGN THE LIABILITY WAIVER! ACKNOWLEDGED AND AGREED TO THIS: I have read and fully understand and agree to the above Participant Liability Waiver and Hold Harmless Agreement. DAY OF Authorized Signature: , 201 By Participant/Parent/Legal Guardian Authorized Signature: Card Number: Expiration Date: CSV: Check Credit Card Cash