Boat & Lake Use Permit Registration Form - Village Of Lake In The Hills Parks & Recreation Department

Boat & Lake Use Permit Registration Form

Payor Last Name_________________________________ Payor First Name_________________________________

Address __________________________________________City_________________________Zip__________

Home Phone______________________________ Cell Phone_____________________________

Email Address ________________________________________________________________

Present and/or mail with all required

Boat Permit - $10 Resident / $7 Res Sr 55+

documentation and check payable to:

Boat Slip - $20 Resident / $15 Res Sr 55+

Village of Lake in the Hills Parks & Recreation

lake Use Permit - $40 Resident / $30 - Res Sr 55+

600 Harvest Gate, Lake in the Hills, IL 60156

$60 - Non-Resident

For More Information call (847) 960-7460

M/S

Color

IDNR Reg #

IDNR Exp Yr

$10/$7

Boat Year

Make/ Model

SliP $20/15

Names of Family Members

Age

Birthdate

M/F

Tag #

Fee

Motor and Sail

Residing at Address

1075-16

$40/$30/$60

boats require

current IDNR

registration

WaiVEr and rElEaSE oF all ClaimS

Please read this form carefully and be aware that in signing up and participating in the above identified programs/activities, 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 said programs/activities (including transportation, when provided).

I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities and I voluntarily agree to assume the full risk

of any and all injuries, damages or loss, regardless of severity, that my minor child and/or I may sustain as a result of said participation. I further agree to waive and

relinquish all claims I or my child/ward may be entitled to (or accrue to me or my child/ward) as a result of participating in these programs/activities against the Village

of Lake in the Hills Parks & Recreation Department including its officials, agents, volunteers and employees.

I do hereby fully release and forever discharge the Village of Lake in the Hills 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 minor child/ward and arising out of, connected with, or in any way associated with these programs/activities.

Participants registering or their parents hereby permit the taking of photos, audio and videotaping during the Parks and Recreation Department activities for publication

and use as the Village deems appropriate.

I have read and fully understand the above information, warning of risk, assumption of risk and waiver and release of all claims.

Signature

Date

oFFiCE USE onlY :Total Paid $_________ Check #_________ Credit ________Cash $_________ Date_________ Initial_______