WAIVER
I agree to waive and relinquish any and all claims that I may have as as result of participating in the program against the SOUTH BARRINGTON PARK DISTRICT, any and all independent contractors, officers, agents, servants and employees of the governmental bodies and independent contractors, and any and all other persons and entities, of whatever nature that might be directly or indirectly liable for any injuries that I might sustain while participating in the program.
I do hereby fully release and discharge the SOUTH BARRINGTON PARK DISTRICT and the parties below from any and all claims for injuries, including death, damage or loss which I may have or which may accrue to me on account of my participation in the program.
I further agree to indemnify, hold harmless and defend the SOUTH BARRINGTON PARK DISTRICT and the below parties, from any and all claims for injuries, including death, damages and losses sustained by anyone, and arising out of, connected with, or in any way associated with my conduct and the program.
Further, in the event of any emergency, I authorize the SOUTH BARRINGTON PARK DISTRICT and the above parties to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my minor child/ward’s immediate care and agree that I will be responsible for payment of any and all medical services rendered.
  
   
   
   
   
   
   
   

Fill out the information below and submit upon completition.

  
     
Family Last Name:   

Address:

 
 

City:

  
 

State:

 
 

Zip Code:

  
 
eMail Address:  
 
Verify eMail Address:  
 
 
  Child's First Name
Age
Code
Class/Program
Fee
     

         
WAIVER        
Please read this form and the waiver carefully and be aware that in participating in the programs listed above, you will be waiving and
releasing all claims for injuries arising out of this program that you or the participant might sustain. The terms "I", "me" and "my" also refer
to the parents or guardians, as well as the participant. In registering for the program, you are agreeing as follows:
As a participant of the program, I recognize and acknowledge that there are certain risks of physical injury, and I agree to assume
the full risk of any injuries including death, damages or loss which I may sustain as a result of participating, in any manner, in any
and all activities connected with or associated with such program. I further recognize and acknowledge that all athletic activities
involving strenuous exertion or potential body contact are hazardous recreational activities and involve subsequent risks of injury.

I understand the nature of the program for which I am registering, and have read and fully understand the WAIVER, release and
hold harmless agreement.
Signature of Parent/Guardian:  
PAYMENT INFORMATION

South Barrington Club House Charge

Account #

Check #

   

Visa #:

Exp:

MasterCard #:

Exp:

Discover #:

Exp:
  Signature:
Date:  
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