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2012 Camp, Clinic & Kidz Zone Registration Form —

Fill out all required parts of this form carefully. Incomplete or inaccurate information will delay your registration. If you are registering for any of our Flex Camps, complete the Registration Section on the reverse side of this form first. New registrants may be required to show proof of residency when registering. See the Camp Registration Info page for valid forms accepted for proof of residency. Please see the Camp Registration & Payment Information page for important registration information and refund policy.

1 Fill in information for head of household – please print

Parent/Guardian Name ___________________________________________________________________________________ Address _____________________________________________________ City _______________________________ Zip _____________________ Home Phone (_______) _____________________ Business Phone (_______) _____________________ E-mail ___________________________

Fill in deposit and Before or After Camp Care information – please print 2A Class ID# p Enroll in Before Camp Care

- - -

p Enroll in Before Camp Care -

p Enroll in Before Camp Care

A $75 deposit per session/per child is allowed for programs costing $150 or greater (unless otherwise noted). After April 1, fees must be paid in full. Programs costing $149 or less must be paid in full. Also select whether or not to enroll in Before Care or After Care for each camp as described on page 2. To enroll, check the box and add this to your total fee.

Grade Program Name p Enroll in After Camp Care p Enroll in After Camp Care p Enroll in After Camp Care

* Deposits and full payments may be paid by cash, check or credit card. If you are making a deposit today you must provide credit card information in Section 4 for the balance due. Balance will be charged to credit card by May 1.

3 4

Camps, Clinics and Kidz Zone Totals Flex Camp Totals (from reverse) Total Fees

2B 2C In accordance with the Americans with Disabilities Act, describe any accommodation needed for your enjoyment of this program:

Complete payment information (make checks payable to the Glenview Park District) Total of fees & deposit you are paying today $ _____________

___ Visa ___ Mastercard ___ Discover ___ Cash ___ Check

* * *

Participant’s First & Last Name Sex B-day as of 1/2012 Total Fee Deposit Balance Due

Balance due after deposit $ _____________ Card holder (print name) ________________________________

Card Number __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Authorized Signature____________________________________ Exp. Date _____________

p I authorize the Glenview Park District to charge my balance due. 5 Sign the Waiver PARTICIPATION WILL BE DENIED if signature of adult participant or parent/guardian and date are not on this waiver.

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 this program/activity, 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 this program/activity (including transportation services/vehicle operation, when provided). I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, 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 this program/activity against the Glenview Park District, including its officials, agents, volunteers and employees (hereinafter collectively referred as “Glenview Park District”). I do hereby fully release and forever discharge the Glenview Park District 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 this program/activity. I understand that photos and videos are periodically taken of people participating in Glenview Park District programs and activities and I agree that any photograph or videotape taken by the park district of me or my minor child/ward while participating in a park district program or activity may be used by the park district for promotional purposes including its electronic media, videotapes, brochures, flyers and other publications without additional prior notice, permission or compensation to the participant. 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 via fax, your facsimile signature shall substitute for and have the same legal effect as an original form signature. Signature of Participant or Parent (if participant is under 18 years)

7 6 Return your form to the park district:


Park Center, 2400 Chestnut Ave., Glenview, Suite P, IL 60026 • Fax: (847) 657-6231. Resident Priority Registration begins at 9 am on Monday, Jan. 9. General Registration begins at 9 am on Monday, Jan. 23. All 2012 camps are non-lottery. Registration is on a first-come, first-served basis.

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