Palatine Park District Registration Form

In case your first choice is filled, list a second choice.   If both choices are filled, you will be placed on a waiting list for your first choice and sent a confirmation card in the mail.  If this form is incomplete or incorrect your registration will be delayed or returned.  Drop off or mail this for to the Palatine Park District, c/o Registration, 250 E. Wood Street, Palatine, IL 60067-5358

Date___________________Payment being made by (last name, first)__________________________________

Home Address______________________________________________________Apt #____________________

City/State/Zip________________________________________________________________________________

Home Phone________________________Work Phone________________________  Moved? (check here)

Drop off or mail this for to the Palatine Park District, c/o Registration, 250 E. Wood Street, Palatine, IL 60067-5358.  All Refunds will be charged a $5 processing fee.  Our refund policy is 100% up to 10 days before class starts and 50% up to 24 hours after 2nd class.  Some classes are non-refundable.  Medical refunds are subject to review.  Please refer to the catalog for more information.  NO NET REFUNDS UNDER $5 WILL BE ISSUED.   Refunds are not given if there is a change of instructor, for one day programs, special events, or classes which are contracted or require a ticket purchases.   Refund requests or class change requests must be completed in person.  Refunds for anything paid by VISA or MASTERCARD will be processed directly through your charge account.  DOES NOT APPLY TO NON-REFUNDABLE DEPOSITS.

ALL PARTICIPANTS MUST SIGN THIS SECTION

By their very nature, many Park District programs involve body contact, substantial physical exertion, emotional stress, and/or use of equipment which represents a certain risk.  It is recommended that you check with your physician prior to participating in Palatine Park District activities.  Palatine Park District does not provide insurance protection for participants in Park District activities.  Please read the following information carefully and be aware that in registering yourself or your minor child/ward for participation in the above program(s), you will be waiving and releasing all claims for injuries you or you child/ward might sustain arising out of the above program(s).  I give my child permission to participate in this program, trip, or activity and hereby waive, release and forever discharge any and all claims against the Palatine Park District or its commissioners, employees or volunteers for damages and/or injuries to the registrant, which may arise from participation in the Palatine Park District programs.  EMERGENCY TREATMENT: a minor may not be treated, even in an emergency, except when, in the opinion of the attending physician, a life is in the balance.  Written consent is required for all treatment given in any hospital emergency room/center.  Consent of a parent or legal guardian is necessary for unmarried minors, under 18, except in cases of extreme emergencies.  TO WHOM IT MAY CONCERN: As a parent and/or legal guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the above minor in the event of a medical emergency which, in the opinion of the attending physician may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed.  This authority is granted only after a reasonable effort has been made to reach me.  The release form is completed and signed of my own free will with the purpose of authorizing medical treatment under emergency circumstances in my absence.   Please list specific medical allergies, medicines, or other conditions on a separate piece of paper to be attached to this form.

Parent/Participant (must sign)________________________________________________Relationship____________________________

Emergency name (other than listed above)___________________________Emergency phone (other than listed above)__________________

Please indicate if any medical information (asthma, diabetes, etc..) or food allergies that staff should be aware of__________________________________________________________________________________