REGISTRATION FORM (815) 838-3621 Ext. 0 FAX: (815) 834-4278
LOCKPORT TOWNSHIP PARK DISTRICT 1911 S. Lawrence Avenue Lockport, Illinois 60441
Registration Form Resident
Non-Resident School District ______
Today’s Date: _________________________________ E-mail: _______________________________________ Participant’s Last Name: ________________________ Home Phone: _________________________________ Address: _____________________________________ Cell Phone: ___________________________________
City: __________________________ Zip: _________ Work #: ______________________________________ Please print clearly – mistakes could delay registration
CLASS CODE PROGRAM
FEE PARTICIPANTS First Name
SEX BIRTHDATE
Credit Card Discover - American Express - MasterCard - Visa
Credit Card #
Expiration: V-Code:
Cash
Check Gift Card Clerk Intitials: TOTAL FEE $
WAIVER, RELEASE OF ALL CLAIMS AND HOLD HARMLESS AGREEMENT FOR THE LOCKPORT TOWNSHIP PARK DISTRICT Please read this form carefully and be aware that, in signing up and participating in Lockport Township Park District programs, you will be waiving and releasing all claims for injuries, arising out of these programs, that you and other named participants might sustain. The terms “I”, “me” and “my” also refer to parents or guardians as well as participants in the program. In registering for these programs, you are agreeing to the following: As a participant in these programs, I recognize and acknowledge that there are certain risks of physical injury, and I agree to assume the full risk of any injuries, damages, or loss which I may sustain as a result of participating, in any manner, in any and all activities connected with or associated with programs. I further recognize and acknowledge that all athletic activities involving strenuous exertion or potential body contact are hazardous recreation activities and involve substantial risks of injury. I agree to waive and relinquish any and all claims I may have as a result of participating in these programs against the Lockport Township Park District, any and all other partici- pating or cooperating governmental units, any and all independent contractors, offi cers, agents, servants, and employees of the governmental bodies and independent contractors, and any and all other persons and entities, of whatever nature, that might be directly or indirectly liable for any injuries that I might sustain while participating in these programs. (The parties described in the preceding sentence are referred to as “released parties” in the remainder of this agreement.) I do hereby fully release and discharge the Lockport Township Park District and the other released parties from any and all claims for injuries, damages and loss which I may have or which may accrue to me on account of my participation in these programs. I further agree to indemnify, hold harmless and defend the Lockport Township Park District and any and all other released parties, from any and all claims for injuries, damages and losses sustained by anyone, and arising out of, connected with, or in any way associated with my conduct and the activities of these programs. I further understand and agree that the terms such as “participation,” “programs,” and “activities” referred to in this Agreement, include all exercises and physical movements of any nature while I am participating in these programs and further include the provision of or failure to provide proper instructions or supervision, the use and adjustment of any and all machinery, equipment, and apparatus, and anything related to my use of the services, facilities or premises involved in these programs, and transportation to and from my events. I understand the nature of these programs for which I am registering, and have read and fully understand this Waiver, Release and Hold Harmless Agreement. I further understand that any advisements or warnings of the particular risks of these programs that I subsequently receive will be incorporated by reference into and become a part of this agreement.
Any allergies or physical handicaps?_________ If yes, please explain: _____________________________________________________________________________________ ____________________________________________________
_______________________________________________________________ Signature of Participant
Signature of Parent or Guardian Required (if Participant is under 18 years of age)
is a Park Partner & Sole Sponsor of L.T.P.D. 7
Check #
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