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Birthddate

Grade

Geender

Barcode

Course N Name

Fee

2nd Choicee 3rd Choice Barcode Barcode

Charge Total_____________

Exp. E Date_________ _____ Signature_____________________________________________

SSignature of parent/gguardian or adult partticipant

Date

______________ __________________________ _____________ ______________ _________________________________________________

PPlease read this form careffully and be aware that in signing up and participatting in this program/activitty, you will be expressly asssuming the risk and lega l liability and waiving andd releasing all claims for innjuries, damages or with this progrram/activity (including transportation services and vvehicle operations, loss which you or your minor child/ward might susttain as a result of participating in any and all activiities connected with and associated a w when provided). I recognize and acknowledge thatt there are certain risks of physical injury to participants in this program/acttivity, and I voluntarily aggree to assume the full risk of any and all injuries, damages or loss, rregardless of severity, thatt my minor child/ward or I may sustain as a result of o said participation. I furtther agree to waive and reelinquish all claims I or myy minor child/ward may hhave (or accrue to me or m my child/ward) as a rresult of participating in thhis program/activity againsst the District, including itts officials, agents, program instructors, volunteers and employees. I hereby aauthorize and give my connsent to the District to photograph/video my cchild (or me), and withoutt limitation, to use such photographs/video p in connnection with promoting/advertising the services, prrograms, and facilities of the District, without conssideration of any kind. I hhave read and fully uunderstand the above impportant information, warnning of risk, assumption of risk, waiver and releasse of all claims, and photo/video authorization. Iff registering online or via fax, my online or facsim mile signature shall ssubstitute for and have thee same legal effect as an original o form signature.

Hold Ha armless Agreemen nt

Card # __ __ __ __ _ – __ __ __ __ _ – __ __ __ __ – __ __ __ __

Circle one: Visa MasterCard M Discoveer Check #_______ ____ Cardholder Name____________ N ________________ _________________

Payment Metho od: For mail-in orr drop-off registrrations only. Do not complete if registering in peerson.

______________ __________________________ _____________ ______________ _________________________________________________

PPlease list the names of any family member needing special asssistance to participate in the program(s) and what accommoddations are needed ___________________________

Participant’s Name (First ( and Last)

M Mail-in registrati tions: Make checkk payable to Fox Valley Park Distr trict. Mail to: Prissco Community CCenter, 150 W. Illlinois Ave., Aurorra, IL 60506

EEmail__________ _______________ ______________ _______________ ______________ _____________________________________________________

H Home Phone ____ _______________ __________ Emergency Phone ____ ______________ ____________ CCell Phone _______________________________

A Address ________ _______________ ______________ ____________ Citty_____________ ____________ Sttate ________ ZIIP ______________________

M Main Contact Last Name _________ ______________ _______________ ___________ Firsst Name ______________________________________________

Need another form? f Download onee from our website: www.foxvalleyparkdis w istrict.org

Fox Vallley Park District Reg gistration FForm

Registration Form foxvalleyparkdistrict.org

Fox Valley Park District Activity Guide Spring 2012  

Fox Valley Park District Activity Guide Spring 2012

Fox Valley Park District Activity Guide Spring 2012  

Fox Valley Park District Activity Guide Spring 2012

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