SPRING/SUMMER 2025 REGISTRATION FORM
Household Last Name
Date of Registration
REGISTER BY MAIL: Village of Willowbrook Parks & Recreation Dept. 835 Midway Drive Willowbrook, IL 60527 REGISTER ONLINE: willowbrookil.org MAKE CHECKS PAYABLE TO:
Address City
State
Zip Code
Phone Number E-Mail Address Emergency Contact Name:
Phone If you or a family member require special assistance in enjoying any of our programs, please check the box at the left. Please explain the situation and we will do our best to accommodate your requests.
Village of Willowbrook QUESTIONS? CALL: (630) 323-8215
CLASS/PROGRAM/TRIP INFORMATION
Code
Class/Program/Trip Name
Participant’s FULL Name
Birthdate M/F
Allergies
Amount
(M/D/YR)
Due
TOTAL
Credit Card Payment (check one) VISA
Master Card
Discover
NO AMERICAN EXPRESS
Account #
3-digit Security Code
Exp. Date
Cardholder Name
Authorized Signature
VILLAGE OF WILLOWBROOK RELEASE AND HOLD HARMLESS WAIVER Please read this form carefully. As a participant in the Class/Program/Trip, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any property damage, physical injuries, including death, damages, or loss which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such program. I agree to waive and relinquish all claims I or minor child/ward may have because of participating in the program against the Village of Willowbrook and its officers, agents, servants, and employees. I do hereby fully release and discharge the Village of Willowbrook and its officers, agents, servants, and employees from any and all claims from property damage, injuries, including death, damages, or loss which I or my minor child/ward may have, or which may accrue to me on account of my participation in the program. I further agree to indemnify and hold harmess and defend the Village of Willowbrook and its officers, agents, servants, and employees from any and all claims resulting from injuries, including death, damages and losses sustained by me or my minor child/ward and arising out of, connected with, or in any way associated with activities of the program. EMERGENCY TREATMENT PERMISSION: I understand that a minor may not be treated, even in an emergency situation, except when, in the opinion of the attend- ing physician, life is in the balance. Consent of a parent or legal guardian is necessary for unmarried minors under 18. Written consent is required for all other treat- ment. Accordingly, as a parent and/or legal guardian, I do herewith authorize the treatment of the minor enrolling in this program in the event of a medical emergency. ACKNOWLEDGMENT: I have read and fully understand Registration Policies, the “Release and Hold Harmless Agreement”, and the “Emergency Treatment Permission.” This release and medical authorization form is complete and signed of my own free will even though I understand it is a requirement for participation in this program.
PHOTO POLICY: On occasion, Village staff may take photographs or video of participants in our programs or events or of people in our parks. I do hereby grant permission for my/our participant’s photograph and/or video to be used in promotional materials related to the Village of Willowbrook. Promotional materials include, but are not limited to brochures and advertising, website, social media outlets, email newsletter, in house publications.
I request that the Village of Willowbrook NOT use this participant’s name and photograph for publicity purposes.
By signing this form I understand that trips and adult athletic deposits are non-refundable. I have read and agree to the above. There will be a $20 service fee for all returned checks.
Participant
Date
Parent/Legal Guardian, if under 18
Date
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