DPParks_Spring Spectrum 2017_v01 February 2017 | 页面 15

Type of Pool Pass ( Please check one ) Mystic Waters ( includes Chippewa & Iroquois Pools ) Chippewa & Iroquois Pools Family Last Name _____________________________________________________ E-Mail _______________________________________________ Address ______________________________________________________________ City _____________________________ Zip ________________ Home Phone ( )___________________________________________ Work Phone ( )___________________________________________

First Name Birthdate M / F Pass Options ( Please check )

Credit Card Payment Check One : Card Number

Has any of the information above changes since your last registration ? Yes No Is this your family ’ s first time registering ? Yes No First time Des Plaines residents : Please provide proof of residency . Residency verified by staff .

Visa MasterCard Discover

Cardholder ’ s Signature _________________________________________ Expiration Date ______________ Total $ __________________________

Cash ____ Check ____ Charge ____ R _______ NR ______

For Office Use Only Total Payment Enclosed $ _____________________________

Waiver

The ( Des Plaines Park District ) “ Park District ” is committed to providing safe aquatic facilities . The Park District continually strives to reduce such risks and insists that all participants follow safety rules and regulations that are designed to protect the participants ’ safety . However , participants and parents / guardians of minors engaged in aquatic activities must recognize that there is an inherent risk of injury .

You are solely responsible for determining if you or your minor child / ward are physically fit and / or adequately skilled for the activities associated with this Pool Pass . It is always advisable , especially if the participant is pregnant , disabled in any way or recently suffered an illness , injury or impairment , to consult a physician before undertaking any physical / aquatic activity .

Warning of Risk Swimming and other aquatic activities challenge and engage the physical , mental and emotional resources of each participant . However , despite careful and proper preparation , instruction , medical advice , conditioning and equipment , there is still a risk of serious injury , including but not limited to drowning , head / brain injury and , spinal cord injury . Understandably , not all hazards and dangers can be foreseen . The very nature of swimming and aquatic activities are hazardous and risky , including but not limited to fatigue , over exertion , poor swimming skills , failing to avoid dangerous areas failing to follow rules and regulations , failure of lifeguards to locate victims and / or delay in emergency response times , horseplay , diving or cannon-balling into shallow water and striking the bottom or striking other swimmers , striking one ’ s head on the bottom , slip and falls on the deck within the locker facility , chemical exposure and all other circumstances inherent to aquatic activities . In this regard , it must be recognized that it is impossible for the Park District to guarantee absolute safety .

Waiver and Release of All Claims and Assumption of Risk Please read this form carefully and be aware that in consideration for this Pool Pass , you will be expressly assuming the risk and legal liability and waiving all claims for injuries , damages or loss which you or your minor child / ward might sustain as a result of participation in any and all activities connected with and associated with use of the Park District aquatic facilities and programs . I recognize and acknowledge that there are certain inherent risks of physical injury to patrons of aquatic facilities , and I voluntarily agree to assume the full risk of any injuries , damages or loss , regardless of severity that my minor child / ward or I may sustain as a result of participation in any and all activities and programs connected with or associated with this Pool Pass . I further recognize and agree that lifeguards and the aquatic staffs are not responsible for supervising my activities or the activities of my minor child ( ren ) and I agree that I am solely responsible for supervising my minor children and / or assessing whether my children are physically fit and / or adequately skilled for aquatic activities . I additionally agree to supervise any children under age 10 at all times .. I agree to the terms of the District Photo / Video Policy .

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 use of the Park District ’ s aquatic facilities and programs against the Park District , including its officials , agents , volunteers and employees .

Never leave any child with poor swimming skills or younger than 10 years of age unaccompanied by a parent or responsible person , 18 years of age or older .

Signature of Participant ________________________________ Signature of Parent / Guardian ________________________________

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