Registration Form Family Last Name Address Home Phone Email Address Parent’s Name City Business Phone
q Please include me in the Resident Insider email newsletter, which contains information on upcoming Parks & Rec programs, classes, and special events.
ADA COMPLIANCE: Please notify staff at time of registration if you require special accessibility or accommodations for your participation in these programs. OFFICE
Participant’s First Name Age Birthdate Sex Code/Sec Program Title Fee USE ONLY Zip
WAIVER AND RELEASE OF ALL CLAIMS 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, when provided).
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 and/or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my child/ward may be entitled to (or accrue to me or my child/ward) as a result of participating in these programs/activities against the Village of Lake in the Hills Parks & Recreation Department including its officials, agents, volunteers and employees.
I do hereby fully release and forever discharge the Village of Lake in the Hills 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 these programs/activities.
Participants registering or their parents hereby permit the taking of photos, audio and videotaping during the Parks & Recreation Department activities for publication and use as the Village deems appropriate.
I have read and fully understand the above information, warning of risk, assumption of risk and waiver and release of all claims. Signature of Participant or Guardian
OFFICE USE ONLY Total Paid $_______________ Check #_______________ Credit_______________ Cash $_______________ Date_______________ Initial_______________
Make Checks Payable & Mail to:
Village of Lake in the Hills 600 Harvest Gate Lake in the Hills, IL 60156 For More Information call 847. 960. 7460
Visit us at:
www.lith.org 8 4 7 . 9 6 0 . 7 4 6 0 www. l i t h . o r g 35
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