Palos Pool Season Passes Last Name ___________________________________________________ New ____ Renewal ____ (Check One) Address __________________________________________________ City __________________ Zip Code _______ Phone # __________________________ Work #________________________ Cell #_________________________ Emergency Contact__________________________ Relationship________________ Phone # __________________ E-Mail Address __________________________________________________________ Family Resident Early Bird Resident Municipal Early Bird Municipal Non-Resident Early Bird Non-Resident I.D. Card $190 $215 $205 $235 $235 $260 $5 each 5th and Up Individual Pass Holders $15 Each $25 each $15 each $25 each $20 each $30 each $5 each $75 $95 $90 $105 $105 $115 $5 each Senior Citizen $60 $80 $65 $95 $80 $100 $5 each Total Due Total The Palos Heights Pool does its best to accommodate individuals with special needs. If you need special assistance, please initial below and we will do our best to assist you. _______ Initials Residents and Municipal Pass Holders must show proof of residency Please make checks payable to City of Palos Heights Cash ________ Check # ____________ Credit Card: Visa Mastercard Discover Please read this form carefully and be aware that in becoming a pass holder you will be waiving and releasing all claims for injuries that you or the family members listed may sustain while visiting the City of Palos Heights Swimming Pool. You recognize and acknowledge that there are certain risks of physical injury and agree to assume the full risks of any injuries, including death, damages or loss which you, or the family members listed may sustain as a result of participating in any and all activities associated with such pass. You further agree to indemnify and hold harmless and defend the City of Palos Heights, its officers, agents, servants and employees from any and all claims resulting from injuries, including death, damages and loss sustained by you or the listed family members and arising out of, connected with, or in any way associated with the pass. You permit the taking of photos, audio and video tapes during City of Palos Heights Swimming Pool hours for publication and use as the department deems necessary. All persons listed on this registration form are immediate family members residing in my household. Any misrepresentation is ground for immediate nonrefundable forfeiture of pass. I have read and fully understand the above Pass Holder information, policies and waiver, releasing the City of Palos Heights of all claims. Signature __________________________________________ Date __________ Signature of parent, guardian, or adult participant 18 years or older Pass Holder Listing Proof of residency for all members listed must be provided before access is permitted into pool. Forms can not be processed until proper registration and fees are paid. False information results in loss of membership without refund. First Name Relationship Birth Day Age M/F A family is defined as 4 immediate family members residing in the same household. Immediate family members are defined as parents and their non-adult (24 & under) children residing in the same household. Senior passes are for persons 60 yrs & older. Valid proof of residence is required for pass purchase. Falsification of address/family information is grounds for non-refundable forfeiture of membership. The City of Palos Heights reserves the right to request a birth certificate for any participant. Office Use Only: # of comp passes given __________ System Entry date ______________ Initials _________ By initialing and dating below, I acknowledge that I have received my complimentary passes Initials _________ Date ___________ Register Today! | Summer 2014 13