CHANNAHON PARK DISTRICT REGISTRATION FORM

I have read and fully understand the warning of risk, and assumption of risk and waiver and release of all claims on the bottom of this form.  If registering via fax, your facsimile signature shall substitute for and have the same legal effect as an original form signature.  We accept cash, check, Visa, and Mastercard.

Date: //2008

Participant Signature : ________________________________

                                    (Parent/Guardian if under 18)

Parent or Guardian First & Last Name:

Participant Last Name (if different from above):

Mailing Address:

City, State, Zip Code

IF PAYING BY CREDIT CARD OR CHECK CARD

Visa     Mastercard

Cardholder #:
Name as appears on card:
Expiration date: /
Signature: ____________________________

                          OFFICE USE

Date Initial Computer Payment
       
       
       
       
     
Home Phone: Work Phone: Email Address:
Participant's First Name Gender Birth Date Grade for
08/09 Year		 Course # Program Title Fee

 

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$

 

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WARNING OF RISK

Recreational activities/programs 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/program. 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, slipping, falling, 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/programs exist. In this regard, it must be recognized that it is impossible for the Channahon 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 and participating in the programs/activities you have indicated on the above, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injury, 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).  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 Channahon Park District, including its officials, agents, volunteers and employees (hereinafter collectively referred as “Channahon Park District”).

I do hereby fully release and forever discharge the Channahon Park District 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.

Photo Policy - On occasion, the Park District staff may take pictures or video of participants in our programs, classes or events.  Please be aware that these pictures are only for Park District use in future catalogues, brochures, pamphlets or flyers.

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