REGISTRATION FORM
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 #
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 .
Activity Name
Beginning Date
$ $ $ $ $ $
Total $
Fee
Office Use
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 ______________________, 201 ________
Authorized Signature : _________________________________________________________ Participant / Parent / Legal Guardian
Authorized Signature : _________________________________________________
�Check �Credit Card �Cash
Card Number : ________________________________________________________ Expiration Date : _________________________________ CSV : __________________
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