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Part 3 Payment Information


□ CREDIT CARD ACCOUNT NUMBER (Tis section must be completed when paying by credit card.) Circle One:


Exp. Date


Name of Cardholder _________________________________________________________________


Authorized Signature ________________________________________________________________Charge Amount$________________________ (Must have signature to be processed.)


By execution of this authorization, the undersigned herby gives the Oak Brook Park District permission to charge the credit card identified here-in for all charges accrued at the Oak Brook Park District for all listed Authorized Individuals. Patrons are responsible to notify the OBPD of any changes of address, credit card or expiration date information.


Keep my card on file. Signature of Cardholder:_________________________________ MY CHECK IS ENCLOSED. Please make checks payable to the Oak Brook Park District. A $25 fee will be charged for all returned checks.


☐ I would like to make a donation (enclosed) to the Oak Brook Park District Foundation in the amount of $_________________ Te Oak Brook Park District Foundation is a nonprofit (501c3) organization committed to assisting the Oak Brook Park District by securing


philanthropic support on its behalf to enhance the use, growth, and preservation of parks, open lands, facilities, and programs. *Make checks payable to Oak Brook Park District Foundation.


WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK: Please read this form carefully and be aware in registering yourself or your minor child/ward for participation in the above program/programs, you will be waiving and releasing all claims for injuries you or your minor child/ward might sustain arising out of your participation in the program/programs you have registered for. I recognize and acknowledge that there are certain risks of physical injury to participants in the above program(s) and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such program(s). I agree to waive and relinquish all claims my minor child/ward or I may have as a result of participating in the program against the District and its officers, agents, servants and employees. I do hereby fully release and discharge the District and its officers, agents, servants and employees from any and all claims from injuries, damage or loss which I or my minor child/ward 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 the activities of the program(s) (including transportation services and vehicle operations, when provided). I further agree to indemnify and hold harmless and defend the District and its officers, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me or my minor child arising out of, connected with, or in any way associated with the activities of the program(s). In the event of any emergency, I authorize District officials to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my child/ward’s immediate care and agree that I will be responsible for payment of any/all medical services rendered. As a participant in a program or activity of the District (or as the parent or guardian of a participant), I hereby grant the District permission to use my or my child’s image, video form, or voice in photographs, videotapes, Internet website or other materials prepared or released by the District from time to time, for promotional, safety or instructional purposes. I understand that such materials will be used and shown in whole or in part as the District sees fit. By this permission and release, I hereby release and discharge the District, its officers, employees and agents from any and all claims or actions resulting from the use of such materials by the District. When registering by fax or online at the Oak Brook Park District, it is mutually understood that the facsimile registration document (including the Waiver and Release of All Claims) shall substitute for and have the same legal effect as the original form. I have read and fully understand the program details and Waiver and Release of All Claims and Assumption of Risk. The Oak Brook Park District does not carry accident or hospitalization insurance on any program participant. It is recommended that participants review their own personal insurance policy for adequate coverage during all program activities.


Part 4 Sign the Registration Waiver □ I have read the program waiver stated on the back and understand that my signature is required in order to participate in any program.


Participant/Parent/Guardian Signature____________________________________________ Date___________________________________ Signature MUST be included for Registration Form to be processed. Part 5 Return your form to Oak Brook Park District


Oak Brook Park District, Administrative Office, 1450 Forest Gate Road, Oak Brook, IL 60523 | phone: (630) 645-9590 | fax: (630) 990-8379


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