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Registration
Last Name:______________________________________ Phone Number:________________________
Participant’s Name: Activity Number Program Name: Day Dates Time Fee
Payment Options:
_____Cash
_____Resident
T-Shirt: YXS YS YM YL AS AM AL XL XXL
_____Check (Check #_________)
X___________________________________________________________________________________________________
Please read this form carefully, and be aware that by registering for and participating in this program, or by registering your minor child/ward for participation in this program, you will be waiving your right and/or the rights of your minor child/ward to all claims for injuries you or your minor child/ward might sustain arising out of this program and you will be required to indemnify, hold harmless and defend the City of Palos Heights of any claims arising out of participation in the above program. As a pareticipant in the program, or as a parent or legal guardian of a participant under 18 yeras of age, I recognize and acknowledge that there are certain risks of physical injury including but not limited to death, damages, or loss and I agree to assume the full risk of injuries which I may sustain as a result of participating in any and all activities associated with this program. I agree to waive and relinquish any claims I may have arising out of, connected with, or in any way associated with the activities of the program. Release from liability: I do hereby fully release and discharge the City of Palos Heights and its officers ,agents and employees from all claims from injuries, including death, damage, or loss which I or my minor may incur on account of participation in this program. I further agree to indemnify, hold harmless, and defend the City of Palos Heights and its officers, agents, and employees from any and all claims from injuries, including death, damages, and losses sustained by me or my minor ward/child and arising out of, or connected with, or associated with the activities of the program. In the event of any emergency. I authorize the public entity to secure from any physician, and/or medical medical personnel any treatment deemed reasonable/necessary for my minor's immediate care and agree that I will be responsible for payment of any and all medical services rendered. I have read, fully understand and agree to the above conditions of participation in the above program. Participation will be denied if the signature of adult participant/parent/guardian and date are not on this waiver.
THIS WAIVER MUST BE SIGNED BY ALL ADULTS 18 YEARS OLD AND OLDER A $3 fee is charged for any transfer to another class or cancellation of class.
_____Non-Resident Membership
_____Visa
_____Non-Resident
_____MC
_____Discover
Total Enclosed: $______________ Do Not Mail Cash
The Palos Heights Rec. Dept. does its best to accommodate those individuals with special needs. If you need any special assistance with a program, please check the box to the left and we will do our best to assist you.
Signature of parent, guardian, or adult participant 18 years or older
Date
Received: Initials_______ Date:_______ Household ID Number: ________________ Receipt Number:______________________
Office Use Only
56
Palos Heights Parks & Recreation | 708.361.1807
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