REGISTRATION FORM
Last Name : Home Phone : Work / Emergency Phone :
Parent ’ s Full Name : Parent ’ s Birth Date :
Address : City : Zip :
Email :
Payment Method ( Please Circle One ): Cash Check Visa Mastercard AMEX Discover
Credit Card Number : Card Expires : CID :
Signature of Card Holder :
Would You Like to Receive the Glen Ellyn Park District ’ s eNewsletter ( Please Circle One _? YES NO
CODE NUMBER ACTIVITY NAME FEE |
PARTICIPANT ’ S FIRST NAME |
SEX |
BIRTH DATE |
Add a donation to the Park District Scholarship Fund ! $ |
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TOTAL FEE $ |
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The Glen Ellyn Park District makes reasonable accommodations in recreation programs to enable persons with disabilities to participate . Please specify below any adaptive equipment , personnel , or other accomodations you need to participate in a program for which you have registered :
WAIVER AND RELEASE OF ALL CLAIMS Please read this section carefully and be aware that in signing up and participating in the above identified programs and activities , you will be expressly assuming the risk and legal liability and availing 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 said programs / activities ( including transportation services , 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 Glen Ellyn Park District , including its officials , agents , volunteers and employees ( hereinafter collectively referred as “ District ”). I do hereby fully release and forever discharge the District from any and all claims or injuries , damages , or loss that my minor child / ward or I may have or which may accrue to me or my minor child / ward arising out of , connected with , or in any way associated with these programs and activities . You may return this waiver and release by mail or fax to the address or fax number listed below . It is mutually understood that the facsimile document shall substitute for and have the same legal effect as the original . PHOTO POLICY : The Glen Ellyn Park District reserves the right to photograph or videotape participants in Park District programs , facilities or parks for the District ’ s promotional use including its electronic media , brochures , flyers and other publications without additional prior notice or permissions and without compensation .
Signature : Date :
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PLEASE RETURN YOUR FORM TO : Via mail to Registration , Glen Ellyn Park District , 185 Spring Avenue , Glen Ellyn , IL 60137 or via fax to ( 630 ) 389-8527 .