Registrat ion Informat ion Home Phone
Adult First Name
Street Address Email Address Work Phone
Village Work Contact
Family Last Name Zip Code
m Yes, I would like to receive the Park District monthly E-newsletter Emergency Phone
Emergency Contact (name and phone) Do You Pay Taxes to: Downers Grove Park District m Yes m No
Participant’s Name Sex Birthdate Class # Program Name
School District 58 mYes m No Fee
School District 99 m Yes m No Class # 2nd Choice Class # 3rd Choice
YES! Donate to the Downers Grove Park District: m $10 m $15 m $25 m Other $ How did you hear about this program(s)?
TOTAL $
Attach check payable to: Downers Grove Park District and mail to 935 Maple Ave., Downers Grove, IL 60515-4997. There will be a $25 service charge for returned checks. 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.
Method of Payment: m Cash m Check #
Check One: m AmEx m MC m Visa m Discover Cardholder Name
m Credit Card -
Authorized Signature
Office Use Only: APN -
Receipt # -
Exp. Date 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 participating 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 illness, 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.
84 Winter & Spring 2013
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
dgparks.org • 630.963.1300
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