Park District of Oak Park

85 www.pdop.org If credit, select card: Account Number _______________________________________________ Cardholder Name_______________________________________________ Expiration Date_______/______ Amount of Charge $_______________ Authorized Signature_____________________________________________ R E L E AS E A N D H O L D H A R M L E S S A G R E E M E N T Please read this form carefully and be aware that in signing up and participating in this program(s), you will be waiving and releasing all claims for injuries you might sustain arising out of this program (including transportation services, when provided). As a participant in the program(s), I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of injuries, damages or loss which I may sustain as a result of participating in any and all activities with or associated with such program(s). I agree to waive and relinquish all claims I may have as a result of participating in the program(s) against the Park District of Oak Park and its officers, agents, servants, and employees. I do hereby release and discharge the Park District of Oak Park and its officers, agents, servants, and employees from any and all claims from injuries, damage or loss which I may have or which may accrue to me on account of my participation in the program(s). I further agree to indemnify and hold harmless and defend the Park District of Oak Park and its officers, agents, servants, and employees from any and all claims resulting from injuries, damages and losses sustained by me and arising out of, connected with, or in any way associated with the activities of the program(s). I have read and fully understand the above Program Details and Waiver Release of all Claims. Waivers MUST be signed by participant(s)' legal guardian. Facsimile signatures will be considered as original by the District. Signature(s):_______________________________________________________________________________________________Date:_______________________ Participant Name Gender Date of Birth School Grade Activity Code # or Pass Code Program or Pass Name Fee First Choice Alternate First Choice Alternate First Choice Alternate First Choice Alternate First Choice Alternate First Choice Alternate Yes, I would like to donate to the Park District of Oak Park Scholarship Fund! $1 $5 $Other (write in amt): Total For insurance purposes, Park District programs/activities require a signed waiver. Photocopies of this sheet accepted! DO NOT MAIL CASH! Office Use Only Is this your household's first time registering for a program at the Park District? Yes No Not Sure In accordance with the Americans with Disabilities Act, describe any accommodation needed for your enjoyment of the programs above: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Name of Participant: ___________________________________________ Household Last Name: First Name: Street Address: Apt: City: Zip: Home Ph: ( ) Work Ph: ( ) Cell Ph: ( ) E-mail Address: ______________________________________________________________________________________ Please add me to your E-News list! Emergency Contact Name & Relationship:_________________________________________________ Emergency Contact Ph: ( ) MAIL, FAX OR DELIVER COMPLETED FORM TO: Park District of Oak Park 415 Lake Street, Oak Park, IL 60302 Fax: (708) 725-2301 (registration also available at the GRC, 21 Lake St) Check (# __________) Cash (in person only) Credit Card PAYMENT INFORMATION Registration Form

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