Page 79 - Winter/Spring 2017

REGISTRATION FORM
Payment Must Accompany Registration
Household Information
Head of Household Address
City
Participant Information
Home Phone Work/Emergency Phone Email Address
Zip
Participant’s First & Last Name
Program Name
Activity Number
Start Date
Sex
Birthdate
Age
Fee
$
$
$
$
$
$
Total
$
Catalog
Payment Information
Social Media Check #
Radio/Newspaper
Other ___________________
How did you hear about the Joliet Park District?
Check Cash Credit Card
$ Amount $ Amount
Visa Billing Address Zip Code
MasterCard
American Express
3 Digit Code
Discover
Account Number
Expiration Date
Billing Address
Cardholder Name $
Amount of Charge
Authorized Signature
Refund Policy
Waiver
Refunds will be issued after the rst meeting of the class, program or activity only if: 1. The District receives written doctor’s excuse accompanied by written request for refund or 2. The registrant moves from the Joliet Park District boundaries. Evidence of the move must accompany a written request for the refund. A class credit can be issued for other reasons if approved by the program staff. Refunds will be prorated for classes attended. Withdrawal from a program is subject to a $5 administrative charge. All refund requests must be made in writing. Classes, programs, etc. cancelled by the District are subject to full refund. Refunds for trips will not be issued after the trip deadline has passed. Please allow 10 business days to receive your refund.
MAIL, DROP OFF, OR REGISTER ONLINE
Joliet Park District 3000 W Jefferson St Joliet, Illinois 60435 phone 815.741.7275 website jolietpark.org
RDC Information (Of ce Use Only) RDC NRDC/Partnership
Proof of Residency
Driver’s License Utility Bill
Type of Picture ID
Driver’s License State ID
Subdivision
Water Bill Tax Bill Voter’s Card
You must sign and date waiver to participate in park district programs. Please read carefully and be aware that in registering yourself or your minor child/ward for participation in the program(s), you will be waiving and releasing all claims for injuries you or your child/ward might sustain arising out of the program(s).
I recognize and acknowledge that there are certain risks of physical injury to participants in the program(s) and I agree to assume the full risk of any such injuries, damages or loss regardless of severity, which my child/ward or I may sustain as a result of participating in any activities connected or associated with any such program(s) including transportation services and vehicle operations when provided. I waive and relinquish all claims I or my child/ward may have against the Joliet Park District and its of cers, agents, servants and employees as a result of participation or the participation of my child/ward in any of the program(s). I further agree to indemnify and hold harmless and defend the park district and its of cers, agents, servants and employees from any and all claims resulting from injuries, damages and loss sustained by me or by my child/ward, arising out of, connected with, or in any way associated with the activities of any of the program(s). I have read and fully understand the program details and waiver and release all claims.
Mandatory signature of participant, parent, or legal guardian Date
Remember:
Resident Discount Cards must be current to receive resident rates.
A.D.A. Statement
Americans With Disabilities Act: Special Needs? Yes No
The Joliet Park District intends to comply with the interest and spirit of the Americans With Disabilities Act. If you need any special accommodations, please call the Park District so that we may make the necessary arrangements for you. Phone 815.741.7275 ext. 169
Photo Disclaimer
Registrants and Participants permit the taking of photos and videos of themselves
and their children during Park District activities for publication and use as the Park District deems necessary.
Registration • 79