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Registration Form

Peoria Park District • Registration Questions? Call (309) 688-3667

Registering for Owens Center, Peoria Zoo, Peoria PlayHouse, Proctor Center, Logan Center, or Luthy Botanical Garden programs?
Please see their individual pages for how to register.
1. Parent/Guardian Information OR Participant Information for ages 18+
First and Last Name: ___________________________________________________________________ Birthdate: _______________
Street Address, City, ZIP:_________________________________________________________________________________________
Home Phone: _________________________ Work Phone: ________________________ Cell Phone: ________________
Email:______________________________________________________________________

2. Registration Information. Please fill out completely and attach an additional sheet if necessary.
Class Code Program Name Participant’s First & Last Name Sex Birthdate Grade & School Fee*
M
F
M
F
M
F
M
F
M
F
I would like to donate $______ to the Scholarship Program to enable disadvantaged youth to participate in programming.
*NOTE: R = Resident (of Park District) Fee • NR = Nonresident Fee • M = Member Fee (where applicable) TOTAL PAYMENT: $________
3. Let us know of any special needs. 4. Coaching Information
We welcome individuals with disabilities. Please PARENTS: Can you serve as a volunteer coach? YES / NO
describe any accommodations needed for If YES, which sport? (circle) Soccer • Basketball
Head or assistant coach? (Circle one)

successful inclusion in the program(s). Your name and phone #: __________________________________________________
_______________________________________ We will consider team requests for carpooling purposes. Detail your request on a separate
_______________________________________ sheet of paper.
_______________________________________

5. Please read and sign the waiver.
Please read this form carefully and be aware in registering yourself, your child or ward for participation in this program you will be waiving and releasing all claims for injuries
you or your minor child/ward might sustain arising out of this program. As a participant in the program or the parent/guardian of a participant in the program, I recognize and
acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, including death, damages or loss which I or my minor child/ward may
sustain as a result of participating in any and all activities connected with or associated with such program. I agree to waive and relinquish all claims I or my minor child/ward may
have as a result of participating in the program against the Park District and its officers, agents, servants and employees. I do hereby fully release and discharge the Park District and
its officers, agents, servants and employees from any and all claims from injuries, including death, damage or loss which I or my minor child/ward may have or which may accrue
to me or my minor child/ward on account of my participation in the program. I further agree to indemnify and hold harmless and defend the Park District and its officers, agents,
servants and employees from any and all claims resulting from injuries, including death, damages and losses sustained by me or my minor child/ward and arising out of, connected
with, or in any way associated with the activities of the program. In case of accident or sickness, I consent to emergency medical care provided by ambulance or hospital personnel.
I hereby consent to the use of my photograph, or that of my minor/child, in Park District brochures, social media, advertisements, etc. I have read and fully understand the above
Program Details and Waiver and Release of All Claims as well as the “Registration Regulations” as listed on the opposing page.

SIGN ____________________________________________ _____________________________________ ___________
HERE Signature of Participant or Parent/Guardian Printed Name Date

6. COMPLETE PAYMENT METHOD Credit Card Number: __________-__________-__________-________
 Check* 3 or 4 Digit Code on Back of Card: ________________
 Cash Expiration Date: ________________
    Authorized Signature: ________________________________________
7. RETURN Printed Name on Card: ________________________________________
By Mail: Peoria Park District Registration
1125 W. Lake Avenue
Peoria, IL 61614 •PLEASE NOTE: When you provide a check as payment, you authorize the PPD to use
information from the check to make a one-time electronic fund transfer from your
account. Funds may be withdrawn from your account as soon as the same day we receive
By Fax: 686-3384 (Credit cards only) your payment and you will not receive your check back from your financial institution.

108 peoriaparks.org • facebook.com/peoriaparkdistrict • twitter.com/peoriaparkdist