Participant's Last Name_________________________ Parent's Full Name______________________

Address_____________________________ City/Zip_________ Phone _______________________

Emergency Contact Name_______________________ Emergency Phone_______________________

Deerfield Park Foundation Scholarship Fund Donation    $5     $10    $25    $ other TOTAL $_______

Donations to the Deerfield Park Foundation are voluntary and tax deductable under the laws of the Internal Revenue Service

General Waiver $ Release

Important Information

The Deerfield Park District is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. The Deerfield Park District continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participant's safety. However, participants and parents/guardians of minors registering for this program/activity must recognize that there is an inherent risk of injury when choosing to participate in recreational activities. You are solely responsible for determining of you or your minor child/ward are physically fit and/or skilled for the activities contemplated by this agreement.
It is always advisable, especially if the participant is pregnant, disabled in any way, or recently suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity.

Warning of Risk

Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a risk of serious injury when participating in any recreational activity/program. Understandably, not all hazards and dangers can be foreseen. Participants must understand that certain risks, dangers and injuries due to acts of God, inclement weather, slipping, falling, equipment failure, in supervision, premises de-fects and all other circumstances inherent to recreational activities/programs for the Deerfield Park District to guarantee absolute safety.

Waiver and Release of All Claims and Assumption of Risk

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 and associated with this program/activity (including transportation services, when provided). I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, and I volun-tarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward of I may sustain as a result of said participation. In the event of an emergency, I authorize District officials to secure from any licensed hospital physician, and/or medical personnel and treatment deemed necessary for me or my minor child's immediate care and I agree that I will be responsible for payment  of any and all medical services required. 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 this program.activity against the Deerfield Park District, including its officials, agents, volunteers, and employees (hereinafter collectively referred to as "Deerfield Park District"). I do hereby fully release and forever discharge the Deerfield Park 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 , 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 a minor participant, I further attest that I have read the above to my minor child/ward.

Participant Signature___________________________________ Date_______________
                                        (18 years or older or Parent/Guardian)