Registration Form

Park Di strict of La Grange Registration Form

Winter 2021

8591 • www.pdlg.org 352 1762 • Fax 708 352 e 708 536 East Avenue, La Grange, IL 60525 • Phon

use only Your email will not be sold f or PDLG

F amily Last Name ____________________ _________________________ Email ___________________________________ ______

__ Address ________________________ ___________________________ City _____________________________ ______________ Zip____________________ Emergency_____________________ ___ Alt.

____ Phone/Home________________________ Cell _ __________________________ Work ________________

Fee

Office Use Only

Program C ode

Start Date

Program Name

Birth Date

Sex

P articipant (First & Last Name)

Total

e Checks payable to: Park District of La Grang Cash □ Check # ______________ Clerk_____________ Credit Card –Last 4 digits___________________________ □ □

: Provide full credit card number and Mail In Registration

exp. date & sign authorization below

_________________________________________ _________ Credit Card # Exp. Date __________________________________________________ Signature

Refunds must be requested no less than 5 days prior to the first class date

Do you need any accommodations, in accordance with the Americans with Disabilities Act, to effectively participate in

No

Yes

the above program?

Details:

responsible I further recognize and agree that lifeguards and other aquatic staff are not agree that I or supervising my activities or the activities of my minor child(ren) and I f Recreational programs are intended to challenge and engage the

:

am solely responsible for supervising my minor children and/or assessing whether my Despite careful and physical, mental, and emotional resources of each participant. children are physically fit and/or adequately skilled for aquatic activities. I additionally proper preparation, instruction, medical advice, conditioning, and equipment, there agree to supervise any children ages 7 and under at all times. is still a risk of serious injury when participating in any recreational program. I do hereby fully release and forever discharge the Park District of LaGrange

ease: Rel

from any and all claims for injuries, damages or loss that my minor child/ward or I may particular activity, participants must understand that certain risks, dangers, and

have or which may accrue to me or my minor child/ward and arising out of, connected injuries due to inclement weather, slipping, falling, poor skill level or conditioning,

with, or in any way associated with this program. e or carelessness, horseplay, unsportsmanlike conduct, premises defect, inadequat defective equipment, inadequate supervision, instruction or officiating, and all other

Photos and video footage are periodically taken circumstances inherent to indoor, outdoor, and water related recreational programs

Photo/Video Policy and Warning :

of people participating in a Park District program or activity, attending a class or event,

District exists. In this regard, it must be recognized that it is impossible for the Park operty. Please be aware that by registering for a or using District facilities or pr of LaGrange to guarantee absolute safety. program or class, participating in an activity, attending an event, or using District

facilities or property, you authorize the District to use these photos and video footage Please read this information

trict publications, advertising, marketing materials, for promotional purposes in Dis carefully and be aware that in registering for and participating in this program, you

brochures, event flyers, social media (including Facebook, YouTube, Instagram, iability and waiving and releasing all will be expressly assuming the risk and legal l

Twitter, and other social media sites operated by the District), and the District’s claims for injuries, damages or loss which you or your minor child/ward might

or permission and without any compensation website without additional prior notice sustain as a result of participating in any and all activities connected with and

to you. All photos and videos are property of the District. rvices, when provided, and associated with this program (including transportation se

By registering for this activity I have read and fully understand the above, warning of exposure to communicable disease). I recognize and acknowledge that there are

o/video policy and risk, assumption of risk, waiver and release of all claims, phot certain risks of physical injury to participants in this program and I voluntarily agree

warning, and behavior code of conduct. If registered online, my online signature will ss, regardless of severity, to assume the full risk of any and all injuries, damages or lo

be substituted for and have the same legal effect as an original hard copy signature. that my minor child/ward or I may sustain as a result of said participation. I further if the signature of adult participan t or

PARTICIPATION WILL BE DENIED agree to waive and relinquish all claims I or my minor child/ward may have (or

Program Waiver and Release of All Claims and Assumption of Risk

Warning of Risk

Understandably, not all hazards and dangers can be foreseen. Dependin g on the

Waiver and Release and Assumption of Risk:

parent/guardian and date are not included. this program against accrue to me or my child/ward) as a result of participating in the Park District of LaGrange, including its officials, agents, volunteers, and

__ ______________________________

employees (hereinafter collectively referred to as “Park District of LaGrange”). Aquatics: I specifically recognize and acknowledge that there are certain inherent _______________________

Signature of Participant 18 yrs. & older o r Parent/Guardian

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 esult of participating in any and all activities minor child/ward or I may sustain as a r