REGISTRATION FORM
Wood Dale Park District Recreation Complex 111 E. Foster Ave. • Wood Dale, IL • 60191 630.595.9333 • Fax 630.595.9699 www.wdparks.org
For Office Use Receipt #
Total Payment
Employee Initial
Resident Non-Resident
Family Last Name
Address
City
Zip
Home Phone
Cell Phone
Emergency Phone
Emergency Name
For mail-in registration only
Total $ ________
Visa/MasterCard/Discover #
Code:
Exp. Date
Authorized Signature _______________________________
Card Holder Name (Print)
Code #
Program Name
Fee
Participant’s First Name M/F Birthdate
Have a program suggestion? Leave it here! _______________________________________________________
Special Accommodations Special services or accommodations will be provided to participants on an “as needed” basis. Please let us know in advance of your special needs.
Please read this form carefully and be aware that in signing up and participating in this program/activity, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with an associated with this program/activity (including transportation services and vehicle operations when provided). I recognize and acknowledge that there are certain risks of physical injury associated with participating in this program/activity, and I voluntarily agree to assume the full risk of any injuries, damages or loss, regardless of severity, that I or my child/ward may sustain as a result of such participation. I fully understand and agree that all exercises including aerobic activities, the use of weights, number of repetitions, and use of any and all machinery, equipment and apparatus designed for exercising shall be at my or my minor child/ward’s sole risk. Not withstanding any consultation or instruction on exercise programs which may be provided by the Wood Dale Park District, it is hereby understood that the selection of exercise program, methods and types of equipment shall be my or my child/ward’s entire responsibility, and that the Wood Dale Park District, including its officials, employees, agents and volunteers (hereinafter collectively“District”) shall not be liable for any claims, demands, injuries, damages, or loss to person or property arising out of or in connection with the use of the services and facilities contemplated by this agreement.
I further agree to waiver and relinquish all claims I or my child/ward may have or which may accrue to me and/or my child/ward as a result of participation in this program/activity. I do hereby fully release and forever discharge the District from any and all claims for injuries, damages or loss that I or my child/ward may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with this program/activity. I have read and fully understand the above important information, warning of risk, assumption of risk and waiver and release of all claims. If registering for programs via fax or on-line through the internet, my facsimile or electronic signature shall substitute for and have the same legal effect as an original form signature.
Signature of Adult/Parent/Guardian 18 years old and older
Date
Signature of Adult/Parent/Guardian 18 years old and older
Date
66 General Information
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