BACK                             Registration Form

Please make check or money order payable to Harrisburg Park District

Last Name: _____________________________First Name: _______________________________
(Parent’s name if registering a minor)

Address: ________________________________________________________________________

City: ___________________________________ Zip Code: _______________________________

Home Phone: _______________________ Work Phone: _________________________________

Emergency Contact: _____________________________ Phone: __________________________

(Optional) Email Address: __________________________________________________________

Shirt Size__________ (Circle one)   Adult   Youth   Resident: _________ Non-Resident:________

Participants Name                   Age/Grade      Program Name         Session       Time          Fee

          $
          $
          $
                                                                                 Total: $

Harrisburg Park District’s Waiver and Release Important Information
The Harrisburg Park District is committed to conducting its recreation programs in a safe and reliable manner and holds the safety
of participants in high regard. The Harrisburg Park District continually strives to reduce such risks and insists that all participants
follow safety rules and regulations that are designated to protect the participant’s safety. However, participants and parents/ guardians
of minors registering for this program/ activity must recognize the inherent risk of injury when choosing to participate in recreational
activities.

Warning of Risk
Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a risk of serious
injury when participating in any recreational activity/program (including transportation services, when provided).

Waiver and Release of All Claims and Assumption of Risk
Please read this information 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, regardless of
severity, that my minor child/ward might sustain as a result of participating in any and all activities connected with and associated
with this program/activity. I recognize and acknowledge that there are certain risks of physical injury to participants in this
program/activity, and I voluntarily agree to assume full risk of my child/ward and myself. I do hereby full release and forever discharge
the Harrisburg Park District from any and all claims for injuries, damages or loss, that my minor child/ward or I may have or which
may accrue to me or my child/ward arising out of, connected with, or in any way associated with this program/activity. I have read
and fully understand the above important information, warning of risk, waiver and release of all claims and assumption of risk. If
registering a minor child/ward, I further attest that I have read the above information to them.

Signature_________________________________________________ Date__________________________
(Parent or Guardian if under 18)