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
Questions 630-789-7090 No phone registration
FAMILY LAST NAME ____________________________________________________________________ DATE _____________________ ADDRESS _______________________________________________ CITY ______________________________ ZIP __________________ PRIMARY PHONE ___________________________________________ WORK PHONE ________________________________________ CELL PHONE ______________________________________________ EMERGENCY PHONE ___________________________________ EMAIL ADDRESS _________________________________________________________________________________________________
DID YOU HAVE A POOL MEMBERSHIP IN PREVIOUS YEARS? Yes __ No __ DO YOU NEED ANY ACCOMMODATION WITH THE AMERICANS WITH DISABILITIES ACT? Yes __ No __ VERIFICATION OF RESIDENCE Completion of this form & payment confirms that the above information is true and the persons reside at the address listed.
First / Last Nme( please list all family members) Date Of Birth Fee
TOTAL FEES $
PAYMENT INFORMATION – check one: oCash oCheck( payable to: Village of Hinsdale) oCredit Card( Online or In-Person ONLY)
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 fish 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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