PROGRAM REGISTRATION FORM Village of Libertyville Recreation Office Or Register Online at www.LibertyvilleRecreation.com Questions: Email jfranklin@libertyville.com
Parent/Guardian Full Name: _________________________________________________________________ Street Address: __________________________________City:_______________________Zip:___________ Cell Phone:___________________________Secondary Phone (if applicable):__________________________ Email (For Class Updates/Correspondence): ____________________________________________________ Are you a Village of Libertyville Resident? _____yes _____no CLASS CODE CLASS TITLE FEE REGISTRANT FULL NAME GENDER BIRTHDATE
Please email jfranklin@libertyville.com if you need accommodation in accordance with ADA to participate effectively in any programs (minimum 2-week notice required). Please call 847-918-7275 to confirm the email has been received.
Credit Card Information (Visa, Mastercard, Discover, American Express)
CHARGE AMOUNT : _______________
Account #: _________ - _________- _________-_________ Expiration: _______________ CVC: ______________
Cardholder Name (Print) _________________________________________________________________________
Authorized Signature ____________________________________________________________________________
READ CAREFULLY : In consideration of The Village of Libertyville ("the Village") granting the Participant the right and opportunity to participate in the program(s) identified in this Registration Form ( "Programs" ), and other good and valuable consideration, the sufficiency of which is hereby acknowledged, the Participant, hereby agree as follows: Acknowledgement and Assumption of Risk of Injury: The Participant acknowledges that there is an inherent risk of injury in the Participant's participation in the Programs, and that, specifically and without limitation of the foregoing, the Programs may involve strenuous exertion or bodily contact that are hazardous recreational activities. The Participant acknowledges and agrees that they have sole responsibility, and the Village has no responsibility whatever, to determine whether the Participant is physically fit and otherwise able to participate in the Programs. The Participant agrees to assume the full risk of any injuries, including death, and at all costs, damages, and losses, including medical bills, that the Participant may sustain as a result of participating in the Programs, or as a result of the condition, maintenance, and use of any public property involved in the Programs. Waiver and Release of Claims for Injury : The Participant shall, and does hereby, waive, release, and relinquish all claims of every kind, including claims for personal injuries, known and unknown, present and future that the Participant may have against the Village and its officers, agents, servants, and employees, arising out of, connected with or in any way related to the Programs or the Participant's participation therein, or as a result of the condition, maintenance, and use of any public property involved in the Programs. Indemnity: The Participant shall, and does hereby, indemnify and hold harmless the Village and its officers, agents, servants, attorneys, and employees from and against any and all claims of every kind, including claims for personal injuries, known and unknown, present and future, that the Participant may have arising out of, connected with, or in any way related to the Programs or the Participant's participation therein, or as a result of the condition, maintenance, and use of any public property involved in the Programs. Interest: The Participant acknowledges and agrees that they have no fundamental property or liberty interest in participating in the Programs, and that their participation in the Programs is conditioned upon the Participant's compliance with all Village regulations and instructions concerning the Program. The Participants have read and fully understands this document and executes it of their own free will and without any reservation whatsoever. Photos and video footage are periodically taken of people participating in a Recreation activity, attending a class or event, or a Village of Libertyville facilities or property. Please be aware that by registering for a program or class, participating in an activity, attending an event, or using the Village of Libertyville facilities or property, you permit the Village of Libertyville to use these photos and video footage for promotional purposes in Village websites publications, advertising, marketing materials, brochures, event flyers, social media (Facebook, Twitter, lnstagram, Youtube) without prior notice of permission. All photos or videos are property of the Village of Libertyville. Signature below of WAIVER ACCEPTANCE from Parent/Guardian/Participant (18 years and older)
Waiver Acceptance: ______________________________________________________________ Date: _____________________________
RECREATION OFFICE: 870 Country Club Drive, Libertyville, 847-918-7275 HOURS: Monday-Friday 7:30am to Noon, 1pm to 4:30pm (Afterhours Dropbox Available) **AFTERHOURS DROP BOX AVAILABLE**
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