Lombard Park District

65 Registration Form PART 1: PARTICIPANT INFORMATION Check here if there are changes to contact information Last Name: Address: City: Zip Code: Home Phone: Work Phone: Cell Phone: PART 3: PAYMENT INFORMATION Method of payment: Cash Check #__________ Credit Visa Mastercard Discover Credit Card Number: Cardholder Name: Cardholder Signature: CVV: Expiration Date: Amount: $ PART 2: FILL IN PROGRAMS FOR EACH PARTICIPANT Program Code Program Name Fee Participant's name Sex Birthday: mm/dd/yyyy Describe any accommodation needed for your enjoyment of this program: PART 4: READ & SIGN WAIVER IMPORTANT INFORMATION The Lombard Park District is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. The Lombard Park District continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants' safety. However, participants and parents/guardians of minors registering for the above listed programs/activities 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 skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled in any way or recently suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity. WARNING OF RISK Recreational activities are intended to challenge and engage the physical, mental and emotional resources of each participant. Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a risk of serious injury when participating in any recreational activity. Understandably, not all hazards and dangers can be foreseen. Depending on the particular activity, participants must understand that certain risks, dangers and injuries due to inclement weather, slip and falls, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defects, inadequate or defective equipment, inadequate supervision, instruction or officiating, and all other circumstances inherent to indoor and outdoor recreational activities exist. In this regard, it must be recognized that it is impossible for the Lombard Park District to guarantee absolute safety. 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 programs listed above, 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 these programs (including transportation services and vehicle operations, when provided). I recognize and acknowledge that there are certain risks of physical injury to participants in these programs, 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 against the Lombard Park District, including its officials, agents, volunteers and employees. 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 online or via fax, my online or facsimile signature shall substitute for and have the same legal effect as an original form signature. Kiddie Campus Preschool–by signing this form, I understand that the Kiddie Campus Preschool deposit is nonrefundable. Participation will be denied if the signature of adult participant or parent/guardian and date are not on this waiver. Email: Do you want to receive the e-newsletter? YES NO Signature of parent, guardian or adult participant: Print name: Date: Register online, or mail, drop-off, or fax: Lombard Park District, Attn: Registration, 820 S. Finley Rd., Lombard, IL 60148 | Fax to: (630) 620-0762 lombardparks.com | (630) 620-7322

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