Lake Use Permit Registration Form - Village Of Lake In The Hills

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LAKE USE PERMIT REGISTRATION FORM
PAYOR LAST NAME______________________________ PAYOR FIRST NAME__________________________
ADDRESS________________________________
CITY___________________________________________ZIP____________
HOME PHONE_________________________ BUSINESS PHONE_________________________
Email Address _____________________ (For confi rmation)
$40
Please check appropriate box:
_____ Please mail our tags
_____ We will pick up our tags at Village Hall
Name of Family Members Age
Birthdate
Sex SR/R/NR
OFFICE USE ONLY
Code/
Residing at Address
Tag Numbers
Section
$30/$40/$60
1075/17
WAIVER AND RELEASE OF ALL CLAIMS
Please read this form carefully and be aware that in signing up and participating in the above identifi ed 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 Vil-
lage of Lake in the Hills Parks & Recreation Department including its offi cials, 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 Depart-
ment 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 of Participant or Parent/Guardian
Date
OFFICE USE ONLY
Total Paid $_________ Check #_________ Cash $_________ Credit $_________Date_________ Initial_______
Make checks payable & mail to:
Village of Lake in the Hills
600 Harvest Gate Lake in the Hills, IL 60156
For More Information call (847) 960-7460
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