VILLAGE OF RIVERSIDE PARKS & RECREATION
Registration Form / Participant Liability Waiver and Hold Harmless Aggreement
Household Name Phone Cell Address City Zip Email
Participant’ s First Name
Date Of Birth
Sex Grade Program Description Code # Time / Day Fee
TOTAL
Please Read This Form Carefully. By registering for and participating in the above mentioned programs, or by registering your minor child / ward for participation in said programs, you are waiving your rights and / or the rights of your minor child / ward to all claims for injuries you or your minor child / ward might sustain arising out of this program and you agree to indemnify, hold harmless and defend the VILLAGE OF RIVERSIDE for any claims arising out of participation in the programs.
In the event of any emergency, I authorize the public entity to secure from any licensed hospital, physician, and / or medical personnel any treatment deemed reasonable and necessary for my minor child’ s immediate care and agree that I will be responsible for payment of any and all medical services rendered.
Any photos or video taken by Village of Riverside employees will become the property of the Village of Riverside and may be used for marketing purposes.
I have read and fully understand and agree to the above stated conditions of participation in the above program( s).
Participant’ s Signature( Signature of Parent or Legal Guardian of Participant Under 18 Years of Age)
Date
OFFICE USE ONLY Payor Name Check # Cash $
Mastercard Visa Discover Diner’ s Club B R
36