Rolling Meadows Program Registration Form   (please print)

PLEASE: CHECKS, MONEY ORDERS OR CHARGES ONLY FOR ALL REGISTRATION. Registration will not be processed without proper and complete information on the registration form.

Home Phone New Information
Last Name Address
City Apt. # Zip Code
Work/EmergencyTele. # Ask For:

PARK DISTRICT WAIVER AND RELEASE OF ALL CLAIMS


Please read this form carefully and be aware that in registering yourself or your minor child/ward for participation in the above program/programs, you will be waiving and releasing all claims for injuries you or your child/ward might sustain arising out of the above program/programs.

I recognize and acknowledge that there are certain risks of physical injury to participants in the above program(s) and I agree to assume the full risk of any such injuries, damages or loss regardless of severity which I or my child/ward may sustain as a result of participating in any activities connected or associated with any such program(s). I waive and relinquish all claims I or my child/ward may have against the Park District and its officers, agents, servants and employees as a result of participating in any of the above program(s). I hereby fully release and discharge the Park District and its officers, agents, servants and employees from any and all claims from injuries, damage or loss which I or my child. ward may have or which may accrue to me or my child/ward on account of my participation or the participation of my child/ward in any of the above program(s). I further agree to indemnify and hold harmless and defend the Park District and its officers, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me or by my child/ward, and arising out, connected with, or in any way associated with the activities of any of the program(s).
I HAVE READ AND FULLY UNDERSTAND THE ABOVE PROGRAM DETAILS AND WAIVER AND RELEASE OF ALL CLAIMS.

 

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Participant or Parent/Guardian Signature                                                             Date

Code

Program
Name/Dates

 Time Day Participants
First Name		 M/F Birth
Date		 Fee
               
               
               
               
               
               
               
               
               
            TOTAL  

Check #_____________ Check Amt.______________

 

MASTERCARD/VISA

Mastercard       Visa             Expiration Date_____
Card No._ _ _ _ _ _ _ _ _ _ _ _ _ _

Amount of Payment_____________________________

Authorization Signature__________________________

SPECIAL ACCOMMODATIONS
If registrant requires any special accommodations or assistance for enjoyment of the program, please state:

_______________________________________________

_______________________________________________

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