REGISTRATION 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
Questions 630-789-7090 No phone registration
FAMILY LAST NAME __________________________________________________________________________________________________________ DATE _______________________________ ADDRESS _____________________________________________________________________ CITY ______________________________________________________ ZIP _______________________ PRIMARY PHONE __________________________________________________________________ WORK PHONE _______________________________________________________________ CELL PHONE _____________________________________________________________________ EMERGENCY PHONE _________________________________________________________ EMAIL ADDRESS ____________________________________________________________________________________________________________________________________________________
VERIFICATION OF RESIDENCE Completion of this form & payment confirms that the above information is true and the persons reside at the address listed .
Code Program Name T-Shirt Participant ’ s Name Gender D / O / B Fee Size
M / F
PAYMENT INFORMATION ( check one ): oCash oCheck oCC * ( Online or In-Person Only ) oM oF oM oF oM oF oM oF oM oF
TOTAL FEES $
Do you need any special accommodations to participate in a program ?______________________________________________________________________________________________________ If yes , please attach an explanation of the needed accommodation . Two week notice is required to ensure accommodations . Do individuals registering for programs have any allergies or dietary restrictions ? Describe ______________________________________________________________________________ o Check here to opt-in to our email newsletters .
WAIVER AND RELEASE
I have read this form carefully , and am aware that by signing this form and registering and participating in , or registering my minor child / ward for and allowing his or her participation in the Programs listed above on this form : ( hereinafter referred as the “ program ”).
I am WAIVING and RELEASING all claims for myself and my minor child / ward arising out of such registration and participation . In consideration of the Village of Hinsdale ( the “ Village ”) accepting me and / or my minor child / ward as a participant in the Program , I hereby agree as follows :
ACKNOWLEDGMENT AND ASSUMPTION OF RISK OF INJURY AND LOSS : I have fully informed myself of all of the details of the Program and have received satisfactory answers to all questions I have concerning the Program and the risks inherent in the Program and believe and represent that I and / or my minor child / ward have the necessary abilities , skills and knowledge to participate in the Program . I recognize and acknowledge that the Program involves risks of bodily injury , death and property loss . I hereby agree to , and do , assume the full risk of any injuries , including death , and of any property loss 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 connected with or associated with the Program .
WAIVER 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 , servants , employees , insurers , related or affiliated individuals or entities , successors and assign arising out of , connected with , or in any way related to the Program or my minor child / ward ’ s participation therein .
INDEMNITY AND DEFENSE : I hereby further agree to indemnify and hold harmless and defend the Village and its officers , agents , servants , employees , insurers , related or affiliated individuals or entities , successors and assigns from any and 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 my or my minor child / ward ’ s participation in the Program .
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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