Camp Guide 2022 | Page 33

2022 Camp and Summer Clinic / Program Registration Form

Fill out all required parts of this form carefully . Incomplete or inaccurate information will delay your registration . If you are registering for any of our Flexible Option Camps , complete the Registration Section on the next page first . New registrants may be required to show proof of residency when registering . See the Camp Registration Info page for valid forms accepted for proof of residency . See the Camp Registration and Payment Information pages for important registration information and refund policy .

1

Fill in information for head of household – please print Parent / Guardian Name ________________________________________________________________________________________________________________________________________________ Address ______________________________________________________________________ City ____________________________________________________ Zip ______________________

Home Phone ______________________________________ Business Phone ____________________________________ Email _____________________________________________

2A

Fill in information for each participant – please print . Camps costing $ 200 or more are eligible for the Payment Plan option as described on page 3 . After March 15 , fees must be paid in full . Camps costing $ 199 or less must be paid in full . Register for summer camps / programs using this form . Summer clinics / programs must be paid for in full when registering .

* Deposits and full payments may be paid by cash , check or credit card . If you are choosing the Camp Payment Plan option you must provide credit card information in Section 4 for the balance due . Balance will be charged the 1st of every month for three consecutive months .

3

2B

Camp and Program Totals Flexible Option Camp Totals ( from next page )

Total Fees

In accordance with the Americans with Disabilities Act , describe any accommodation needed for your enjoyment of this program :

2C

* * *

4 p check to indicate participant ( s ) require assistance from NSSRA .

Complete payment information ( make checks payable to the Glenview Park District )

Total of fees & deposit you are paying today $ _____________

Balance due $ ____________________________________________________ ___ Visa ___ MasterCard ___ Discover ___ Cash ___ Check Card holder ( print name ) ___________________________________________ Card Number __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Authorized Signature ______________________________________________ Exp . Date _____________ p I authorize the Glenview Park District to charge my balance due .

5

Sign the Waiver PARTICIPATION WILL BE DENIED if signature of adult participant or parent / guardian and date are not on this waiver . Waiver and Release of All Claims and Assumption of Risk

Please read this form carefully and be aware that in signing up and participating , in this program / activity , you will be expressly assuming the risk and legal liability and waiving 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 this program / activity ( including transportation services / vehicle operation , when provided ).

I recognize and acknowledge that there are certain risks of physical injury to participants in this program / activity , 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 this program / activity against the Glenview Park District , including its officials , agents , volunteers and employees ( hereinafter collectively referred as “ Glenview Park District ”).

I do hereby fully release and forever discharge the Glenview 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 this program / activity .

I understand that photos and videos are periodically taken of people participating in Glenview Park District programs and activities and I agree that any photograph or videotape taken by the park district of me or my minor child / ward while participating in a park district program or activity may be used by the park district for promotional purposes including its electronic media , videotapes , brochures , fliers and other publications without additional prior notice , permission or compensation to the participant .

I have read and fully understand the above important information , the refund , transfer and program policies , warning of risk , assumption of risk and waiver and release of all claims . If registering via fax , your facsimile signature shall substitute for and have the same legal effect as an original form signature .

6

Signature of Participant or Parent ( if participant is under 18 years )

Return your form to the park district : Park Center , 2400 Chestnut Ave ., Glenview , IL 60026 • Fax : 847-657-6231 . Resident Priority Registration , January 11-31 . Nonresident and general registration begins February 1 .

Date