This page contains a Flash digital edition of a book.
REGISTRATION FORM


Home Phone (______)________________ Adult First Name ________________________ Family Last Name ________________________________________ Street Address ___________________________________________ Village ___________________________ Zip Code ________________________________ Email Address ________________________


Emergency Phone (______)________________ Emergency Contact______________________________________________ Participant’s Name


DO YOU PAY TAXES TO: Downers Grove Park District m Yes m No Sex Birthdate Class #


Program Name


School District 58 m Yes m No Fee


School District 99 m Yes m No Class # 2nd Choice Class # 3rd Choice ___ Work Phone (______)___________________ Work Contact__________________________________________


YES!Donate to the Downers Grove Park District: m$10 m$15 m$25 mOther $______ How did you hear about this program(s)? _______________________________ TOTAL $


Attach check payable to: Downers Grove Park District & mail to 935 Maple Ave., Downers Grove, IL 60515-4997. Credit card registrations may be faxed to (630) 963-5884. When sent by fax, it is mutually understood that the fax document shall substitute for and have the same legal effect as the original document. If first choice is filled, you will be placed in next available choice. If second choice fee is different than first choice fee, please pay the higher amount. A refund will be made if necessary. There will be a $25 service charge for returned checks.


Method of Payment: mCash mCheck # ___________ mCredit Card Office Use Only: APN ___________ Receipt # __________ _______________________________________________________________________________________________________________


Check One: mVisa mMC mAmEx mDiscover ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ Exp. Date____ Cardholder Name ____________________________ Authorized Signature ____________________________ Amount: $ ________________


This “WAIVER AND RELEASE OF ALL CLAIMS” must be signed by all participating adults and/or one parent or custodial parent or guardian of children under 18 years of age. Without the proper signatures, your registration cannot be processed and will be returned to you.


WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK


Please read this form carefully and be aware that in signing up and participat- ing in the above identified programs/activities, 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 said programs/activities (including transportation services/vehicle operation, when provided). The Downers Grove Park District (herein collectively referred to as “the


District”) is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. The District continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participant’s safety. However, participants and parents/guardians of minors registering for this program must recognize that there is an inherent risk of injury when choosing to participate in recreational activities/programs. You are solely responsible for determining if you or your minor child/ward


are physically fit and/or adequately skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, suffers from an underlying medical condition, or has recently suffered an ill- ness, injury or impairment, to consult a physician before undertaking any physical activity. 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 District, including its officials, agents, volunteers and employees.


80 l Autumn 2011 l www.dgparks.org l 630.963.1300


Photography/videotaping waiver Photographs and videos are taken by Park District staff to use for promotional purposes. By registering for a program, attending an event or using a Park District facility, you have granted us permission to use your image for promotional purposes.


Signature Required I have read and fully understand the waiver and release of all claims on this page and the refund policy. This waiver form is completed and signed of my own free will.


PLEASE SIGN HERE. All adult participants must sign; one parent or custodial parent or guardian must sign if participant is under the age of 18 years.


SIGNATURE SIGNATURE


The Downers Grove Park District strives to comply with the 1990 Americans with Disabilities Act.


DATE DATE SPECIAL ACCOMMODATIONS AND FOOD ALLERGIES


m Check here if any participant needs special assistance or accommodations to participate in programs.


Participant’s Name __________________________________________


Program Name _____________________________________________ m Check here if any participant has a food-related allergy. Participant’s Name __________________________________________ Program Name _____________________________________________


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84