Skokie Registration Form

___ Cash   ___Check #(____________________)            ___Credit Card (circle one)       VISA       MASTERCARD

Parent/Adult Name__________________________Card No.____________________Exp. Date______________

Address______________________Apt. #_______Amount of Payment__________________________________

City & Zip________________________________Authorized Signature_________________________________

Home Phone_______________Work Phone________________Email Address___________________________

Emergency Contact Info                    Name_______________________________

Address____________________________Apt. #________City/State/Zip_______________________________

Phone__________________________________________Relationship to Family__________________________

(please indicate 2nd choice programs with a check)

How did you hear about our programs? (check all that apply)

This guide          Radio          Pamphlet              Newspaper       Flyer     Poster    Outdoor banner

Internet               Cable           Electronic sign     Friend                Other:_________________________

Release and hold harmless agreement: Participants 18 years of age or older and parents of participants under the age of 18 should 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 or damages you might personally sustain which might arise out of this program.  As a participant in this program (or as a parent of a minor participant), I recognize and acknowledge that there are certain risks of physical injury associated with such participation, and I agree to assume the full risk for any injuries, damages, or loss which I may sustain as a result of participating (or of my minor child's participation) in such program as against the Skokie Park District, its officers, agents, servants, and employees.  I do hereby fully release and discharge the Skokie Park District and its officers, agents, servants, and employees from any and all claims from injuries, damages, or loss which I may have or which may accrue to me on account of my participation (or on account of my minor child's participation) in the program.  I further agree to indemnify, hold harmless, and defend the Skokie   Park District and its officers, agents, servants, and employees from any and all claims resulting from injuries, damages, and losses sustained by me and arising out of, connected with, or in any way associated with the activities of the program (or my minor child's participation in the activities of the program).  I have read and fully understand this release and Hold Harmless Agreement and any program details provided to me.  It is mutually understood that the facsimile registration document (including waiver and release of all claims) shall substitute for and have the same legal effect as the original form.

________________________________________                  ____________________________________________

Participants Signature/Date                                                         Parent/Guardian Signature (if participant is under 18)/Date

SKOKIE PARK DISTRICT  9300 WEBER PARK PLACE      SKOKIE, IL 60077   FAX (847)-763-2025