PALATINE PARK DISTRICT REGISTRATION FORM palatineparks.org • 847.991.0333
Please print all information and fill out entire form. Incomplete forms will be returned, which will delay the processing of your registration Head of Household Last Name: _______________________________________________________ First: __________________________________ Address: ______________________________________________________________________________ Apt #: _________________________________ City/State/Zip: __________________________________________________________________________________________________________________ Primary Phone: ___________________________
Cell Phone: _____________________________ Work Phone: ___________________________
Email: _________________________________________________________________________________ Yes, add me to the PPD email list
Americans With Disabilities Act Need Accommodations NWSRA Inclusion Assistance needed for (name of participant requiring special accommodations): __________________________________________________________________________________
Prog #
Program Name/Membership Type
Participant’s Full Name
Current Grade
Birthdate
Gender
Fee
M F M F M F M F M F I would like to make a donation to the Palatine Park Foundation Scholarship Fund 501(c)(3) $1 $3 $ _________________ Please fill out if applicable. Shirt Size: Youth S M L Adult S M L XL School Attending: ______________________________
TOTAL $
TRANSFER/WITHDRAWAL AND REFUND POLICY: If you have any questions about Palatine Park District’s Transfer/Withdrawl and Refund Policy, please contact Christine Hubka, Customer Service Manager, at 847.496.6223 or chubka@palatineparks.org. To submit a refund request, an Application for Transfer/Withdrawal Form must be submitted. The form can be downloaded from palatineparks.org or can be picked up at Community Center, Birchwood Recreation Center, or Falcon Park Recreation Center. Telephone requests will not be accepted. All approved refunds will be applied as a household credit unless otherwise requested on the Application for Withdrawal/Transfer form. If a refund other than household credit is requested, a $5 processing fee will be applied. If requested, approved refunds will be made via check for cash or check payments, or will be refunded back to the original card number used for credit card payments. Please note, refunds via check can take 10–21 days to process. Approved refunds of less than $10 will only be processed as household credits. Refunds/Transfers are not given for special events, trips, or one-day programs unless the event is canceled by Palatine Park District. Refunds/Transfers are not given for passes or memberships. Some programs have separate refund policies which will be noted next to the program information. Medical Request: A note from a physician is required for medical exceptions. Approved medical exception refunds will be prorated from the time the request is received. Medical exceptions cannot be processed after the class has ended. PRIVACY POLICY: To view the Palatine Park District Privacy Policy visit palatineparks.org.
RELEASE AND HOLD HARMLESS WAIVER
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. Additionally participation includes possible exposure to, and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. It is recommended that you check with your physician prior to participating in Palatine Park District activities.Additionally, I and my minor child/ward understand our responsibility for adhering to the rules and regulations for protection against communicable diseases and agree to follow current guidelines and recommendations to mitigate these risks for ourselves and other participants while engaged in Park District programs or on Park District property. Current recommendations/mandates include: Keeping a social distance of 6’ whenever possible, Wearing a face covering when in public, indoors, or outdoors when social distance cannot be maintained, Wash your hands often with soap and water or hand sanitizer when soap/water is not available, Avoid touching your eyes, nose and mouth especially with unwashed hands, Stay home if you are feeling unwell or have a temperature. 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 or illnesses you or your 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, illnesses and/or injuries to the registrant, which may arise from participation in 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..
Release and Hold Harmless Statement on registration form must be signed. PARTICIPATION WILL BE DENIED if the signature of adult participant or parent/ guardian and date are not on this waiver. My signature, or my guardian’s signature if I’m under 18, indicates that I HAVE READ AND FULLY UNDERSTAND THE REFUND POLICY AND WAIVER and understand it is required to take part in Park District programs. Signature: _________________________________________________________________________ Date: _____________________________________ Signature: _________________________________________________________________________ Date: _____________________________________ Signature: _________________________________________________________________________ Date: _____________________________________ Signature: _________________________________________________________________________ Date: _____________________________________ Emergency Name: ________________________________________________________________ Emergency Phone: _______________________ Please indicate below any medical information (asthma, diabetes, etc.) or food allergies that staff should be aware of. ___________________________________________________________________________________________________________________________________________________________________________________
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Photo _____ Gym _____ Processed by __________ Batch # ________________ Verification ____________
