Fillable Participant Information And Waiver Form printable pdf download

Wheaton Park District, Lincoln Marsh Challenge Course

(Teams, High Ropes, Climbing Tower, Power Pole and Crate Stacking)

Participant Information & Waiver form

p.630-871-2810

f.630-871-9213

PLEASE PRINT ALL INFORMATION

Program Date:________________________________ Group Name:__________________________________

First Name:__________________________________________ Last Name_____________________________

Street _________________________________________ City, State________________ Zip_______________

Phone (Home) ______________________________________ (work)_________________________________

Birthdate ___/___/___

M___ F___

Emergency Contact Name _________________________________ Relationship:________________________________

Emergency Phone # _________________________________________________________________________________

Medical information

Allergies ______________________________________ Injuries_____________________________________________

My child requires use of epi-pen

Yes No

Did they bring it today

Yes No

My child requires the use of an inhaler

Yes No

Did they bring it today

Yes No

Any other medical information we should be aware of: (ex: diabetes, epileptic, back problems, etc.)

__________________________________________________________________________________________________

IMPORTANT INFORMATION

The Wheaton Park District is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. The Wheaton Park District

continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. However, participants and

parents/guardians of minors registering for this program/activity must recognize that there is an inherent risk of injury when choosing to participate in recreational activities/programs.

You are solely responsible for determining if you or your minor child/ward are physically fit and/or adequately skilled for the activities contemplated by this agreement. It is always advisable,

especially if the participant is pregnant, disabled in any way or has recently suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity.

On Occasion, park district staff may photograph or videotape participants in park district classes/program or at park district facilities/events. These photos and videotapes are for park district

use only, and may be included in publications, brochures, pamphlets, flyers and videos.

WARNING OF RISK

The Lincoln Marsh Challenge Course is a series of challenging activities that engage the physical, mental and emotional resources of each participant. Despite careful and proper preparation,

instruction, medical advice, conditioning and equipment, there is still a risk of serious injury, including cervical spine injury and head/brain injury. Understandably, not all hazards and dangers

associated with the challenge course can be foreseen. Participants must understand that certain risks, dangers and injuries due to acts of god, inclement weather, slips and falls, insects,

defective equipment, failure in supervision or instruction, premises defects and other circumstances inherent to outdoor settings and recreational activities can exist. In this regard, it must be

recognized that it is impossible for the Wheaton Park district to guarantee absolute safety

WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK

Please read this form carefully and be aware that in signing up and participating in this program/activity, you will be expressly assuming the risk and legal liability and waiving and releasing

all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with this

program/activity (including transportation services and vehicle operations, when provided).

I recognize and acknowledge that there are certain risks of physical injury to participants in the challenge course, and I voluntarily agree to assume the full risk of any and all injuries, damages

or loss, regardless of severity, that my minor child/ward or I may sustain as a result of participating in any and all activities connected with or associated with the challenge course.. I further

agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in this program/activity against the Wheaton Park

district, including its officials, agents, volunteers and employees here in collectively referred to as “Park District”. I do hereby fully release and forever discharge the park district form any and

all claims for injuries, damages or loss that my miner child/ward or I may or which may accrue to me or my miner child/ward and arising out of, connected with, or in any way associated with

the challenge course.

I have read and fully understand the above important information, warning of risk, assumption of risk and waiver and release of all claims. If registering on-

line or via fax, my on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature.

PLEASE PRINT

Participant’s Name ____________________________________ Date: _______________________________________

Participant’s Signature ______________________________ Parent Signature: ___________________________________

(18 years or older or Parent/Guardian)

PARTICIPATION WILL BE DENIED

If the signature of adult participant or parent/guardian and date are not on this waiver.