Waiver Form YOU MUST COMPLETE THE WAIVER FORM OR YOUR ORDER WILL BE ON HOLD. Step 1 of 4 25% O'Fallon Parks & Recreation Waiver and Release The O’Fallon Parks and Recreation is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. The O’Fallon Parks and Recreation 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. You are solely responsible for determining if you or your minor child/ward are physically fit and/or skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled in any way or recently suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity. 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. Understandably, not all hazards and can be foreseen. Participants must understand that certain risks, dangers and injuries due to acts of God, inclement weather, slipping, falling, equipment failure, failure in supervision, premises defects and all other circumstances inherent to recreational activities/programs exist. In this regard, it must be recognized that is impossible for the O’Fallon Parks and Recreation to guarantee absolute safety. Please read this form carefully and be aware that in signing up and participating in the program/activity, you will be expressly assuming the risk and 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, when provided). I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, 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 said participation. 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 O’Fallon Parks and Recreation District, including its officials, agents, volunteers and employees (hereinafter collectively referred as OPR). I do hereby fully release and forever discharge the OPR from any and all claims for injuries, dames, 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 this program/activity. As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the minor (listed) in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. The authority is granted only after reasonable effort has been made to reach me. I have read and fully understand the above important information, warning of risk, and waiver and release of all claimsCamper's Name* First Last Signature of Parent/Guardian* Date* Emergency DataChild #1* First Last Birthdate* Medical Conditions/ Allergies (food or meds) and Treatments Child #2 First Last Birthdate Medical Conditions/ Allergies (food or meds) and Treatments Child #3 First Last Birthdate Medical Conditions/ Allergies (food or meds) and Treatments Name of Parents or GuardiansIn Home* Not In Home* Release to non-custodial parent/guardian* Yes No Not Applicable Parent/Guardian's Work Phone*Parent/Guardian's Cell Phone*Secondary Parent/Guardian Work PhoneSecondary Parent/Guardian Cell Phone Authorized Pick Up List (other than parent)Name (or type none)* Relationship Name Relationship MedicalDoctor* Hospital* Please read the following information and initial:Initial below to confirm you have read the following: Payments are due 7 days before camper attends camp. There will be a payment schedule on your receipt . The $20 deposit you put towards camp is non-refundable unless you give us 7 DAYS NOTICE. A $10 LATE FEE WILL BE APPLIED TO ALL LATE PAYMENTS.* Initial below to confirm you have read the following: If you do not show up for a week you are registered for and do not give us 7 DAYS NOTICE you will be responsible to pay the full billing price for that week (this means the Monday before you start camp...not the Friday)* Initial below to confirm you have read the following: ALL changes to camp registration must be made at least 7 days in advance and must be in writing to the Recreation office using Change of Camp form (email, fax acceptable). NO verbal changes will be honored. A fee of $10 will be assessed to late (this means the Monday before you start camp…not the Friday) (Change of Camp Form can be downloaded off the website).* Initial below to confirm you have read the following: ALL Campers MUST be signed in and out by a parent/guardian EVERYDAY. Please make the camp staff aware of who will be picking your child up each week. If someone new picks up your child and they are not on the authorized pick up your child will not be released. Make sure all authorized pick ups bring ID.* Initial below to confirm you have read the following: If you are late picking up your camper, a late fee will be assessed after 5 minutes and every 5 minutes thereafter at a rate of $5.00* Initial below to confirm you have read the following: Once camp starts changing to another camp may only be done on the Monday - no camp moves will be made after Monday.* Please Click Submit , You will be redirected for payment information. Δ
