POOL PASS MEMBERSHIP FORM - Village of Hinsdale Parks and Recreation
Mail-in or Drop – off : Village of Hinsdale 19 E Chicago Ave , Hinsdale
Fax : 630-789-7016
Online : www . villageofhinsdale . org / pr
FAMILY LAST NAME __________________________________________________________________________________________________________ DATE _______________________________ ADDRESS _____________________________________________________________________ CITY ______________________________________________________ ZIP _______________________ PRIMARY PHONE __________________________________________________________________ WORK PHONE _______________________________________________________________ CELL PHONE _____________________________________________________________________ EMERGENCY PHONE _________________________________________________________ EMAIL ADDRESS ____________________________________________________________________________________________________________________________________________________
Is this registration for the Super Pass Lottery ( Residents Only — March 1-20 )? o Yes o No If yes , would you like to be placed on the Super Pass wait list if you should not receive one ? o Yes o No Did you have a pool membership in previous years ? o Yes o No Do you need any accommodations with the Americans with Disabilities Act ? o Yes o No
VERIFICATION OF RESIDENCE Completion of this form & payment confirms that the above information is true and the persons reside at the address listed .
Questions 630-789-7090 No phone registration
First / Last Name ( please list all family members ) Date Of Birth FEE *
* Nanny passes are NOT included with a family membership . Please note separate nanny pass rates on the previous page . TOTAL FEES $
PAYMENT INFORMATION ( check one ): oCash oCheck oCC * ( Online or In-Person Only )
o Check here to opt-in to our email newsletters .
WAIVER AND RELEASE
I have read this form carefully , and am aware that by agreeing to this form and registering my minor child / ward for and allowing his or her participation at the Hinsdale Community Swimming Pool ( hereinafter referred to as the “ Pool ”), I am WAIVING and RELEASING all claims for myself and my minor child / ward arising out of such participation . In consideration of the Village of Hinsdale ( the “ Village ”) accepting me and / or my minor child / ward as a participant at the Pool , I hereby agree as follows :
ACKNOWLEDGEMENT AND ASSUMPTION OF RISK OF INJURY AND LOSS : I have fully informed myself of all of the details of the Pool and have received satisfactory answers to all questions I have concerning the Pool and the risks inherent at the Pool and believe and represent that I and / or my minor child / ward have the necessary abilities , skills , and knowledge to participate at the Pool . I recognize and acknowledge that the Pool involves risks of bodily injury or death . I hereby agree to , and do , assume the full risk of any injuries , including death , and of all expenses , costs , damages and losses that I , or my minor child / ward on whose behalf I am signing may sustain as a result of participating in any and all activities at the Pool .
WAIVER OF AND RELEASE OF CLAIMS : I hereby agree to , and do waive , release and relinquish all claims , demands , rights of action , damages , liabilities and controversies of every kind , known and unknown , present and future , that I , or my minor child / ward on whose behalf I am signing may have against the Village and its officers , agents , employees , insurers , related or affiliated individuals or entities , successors and assign arising out of , connected with , or in any way related to the Pool or my minor child / ward ’ s participation therein .
INDEMNITY AND DEFENSE : I hereby further agree to indemnity and hold harmless and defend the Village and its officers , agents , employees , insurers , related or affiliated individuals or entities , successors and assigns from any all claims , lawsuits , demands , damages , liabilities , losses and expenses , including attorney ’ s fees and administrative expenses , of every kind , known and unknown , present and future , arising out of , connected with , or in any way related to me or my minor child / ward ’ s participation at the Pool . EMERGENCY CARE : In the event of an emergency , I authorize the Village to secure , from any licensed hospital , physician and / or other medical personnel , any treatment deemed reasonable and necessary for myself and / or my minor child / ward ’ s immediate care and agree that I will be responsible for payment for any and all such treatment rendered .
I have read and fully understand the above WAIVER & RELEASE OF ALL CLAIMS and execute it of my own free will and without any reservation whatsoever .
Sign Here :
_______________________________________________________________________________________________________________________________________________________________________________________ Signature of parent , guardian , or an adult participant 18 years or older
Date
Participation will be denied if the signature of adult participating / parent / guardian and date are not on this waiver .
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