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PROGRAM REGISTRATION FORM
Primary Household Contact (Last) __________________________________ (First)________________________________________________
Address ________________________________________________ City/State ______________________ Zip __________________
Primary Phone ____________________________________________ Email ________________________________________________
Do you need an Americans with Disabilities Act Accommodation? NO YES (Please describe any accommodations needed for successful inclusion)
Total Registrant’s
Program Code Program Title Fee Due First Name Age Birth Date Grade School Attended
Total Fees Email registration to robin@niles-parks.org
METHOD OF PAYMENT: Name: Exp. Date:
Cash American Express (as it appears on card)
Check MasterCard Card Number:
Visa Discover
Remit to: Niles Park District Registration
Signature: Amount:
6676 W. Howard St.
Niles, IL 60714 A self-addressed envelope must be enclosed in order to receive a receipt.
wAiVER AnD RElEASE oF All ClAiMS Please read this form carefully and be aware that in signing up and participating in this program you
will be waiving and releasing all claims for injuries you might sustain arising out of this program.
Please read this form carefully and be aware that in signing up and participating in the above identified programs/activities, 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 and associated with said programs/activities
(including transportation services/vehicle operation, when provided).
I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss,
regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my
child/ward) as a result of participating in all these programs/activities against the Niles Park District, including its officials, agents, volunteers and employees (here-in after collectively referred as “District”).
I do hereby fully release and forever discharge the District from any and all claims for injuries, damages, or loss that my minor child/ward or I 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 these programs/activities.
If registering on-line or via fax, your on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature.
Additionally, by signing this form, I am certifying that I qualify for the rate charged (i.e. If resident rate was charged, I am/my children are residents of the Niles Park District). If this is proven untrue, I realize
that my park district privileges may be suspended or revoked.
Photos are periodically taken of participants in a class, during a special event or at the District’s parks. Please be aware that these photos are for Park District use only and may be used in the District’s
publications.
I have read and fully understand the above important, warning or risk, assumption of risk and waiver and release of all claims.
PLEASE PRINT Participant’s Name
Participant’s Signature (18 years or older or Parent/Guardian) Date
PARTICIPATION WILL BE DENIED if the signature of adult participant or parent/guardian and date are not on this waiver.
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