Parks & Recreation | Registration Form & COVID Waiver CHECKOUT

2. 

4. Participant's Name*

5. Email Address*

7. Address*

8. City, State

9. Zip Code

11. Program Desired*

    1. Adult Steppers | Singles ($70)
    2. Martial Arts | Ages 5-11 | 6pm-7pm ($65)
    3. Martial Arts | Ages 12 & Up | 7:30pm-8:30pm ($65)
    4. Paint Night | March 12 | "Kiss Me" ($35)
    5. Paint Night | March 26 | "Peace" ($35)
    6. Paint Night | April 9 | "Skyline Sunset" ($35)
    7. Paint Night | April 23 | "Visions" ($35)
    8. Paint Night | May 7 | "Electric Lady" ($35)
    9. Paint Night | May 21 | "Sip Happens" ($35)

12. Phone

14. Richton Park | COVID-19 Volunteer & Participant Waiver

16. In consideration of myself and/or my child being allowed to participate in any of the Village of Richton Park activities, I grant the Village, its officials, agents or employees full permission to do a temperature scan on myself and/or my child and monitor for symptoms of COVID-19, which may include being asked a series of questions:

18. Have you had any COVID-19 symptoms (fever, cough, difficulty breathing, chills, headache, muscle pain, sore throat, or loss of taste or smell)?

    Have you had any COVID-19 symptoms (fever, cough, difficulty breathing, chills, headache, muscle pain, sore throat, or loss of taste or smell)?

19. Choose One*

    1. YES
    2. NO

21. Have you been in contact with anyone who recently traveled to any domestic or international travel to areas under the emergency travel orders listed on the CDC (Center for Disease Control and Prevention), IDPH (Illinois Department of Public Health) and CCDPH (Cook County Department of Health) webpages?

    Have you been in contact with anyone who recently traveled to any domestic or international travel to areas under the emergency travel orders listed on the CDC (Center for Disease Control and Prevention), IDPH (Illinois Department of Public Health) and CCDPH (Cook County Department of Health) webpages?

22. Choose One*

    1. YES
    2. NO

24. I understand and agree that if I and/or my child has a temperature, shows symptoms of COVID-19 or answers any questions in the affirmative, I and/or my child shall not be allowed to participate in any Village of Richton Park activities.

    I understand and agree that if I and/or my child has a temperature, shows symptoms of COVID-19 or answers any questions in the affirmative, I and/or my child shall not be allowed to participate in any Village of Richton Park activities.

25. Choose One*

    1. YES
    2. NO

27. I hereby agree and understand that the terms and provisions of the Participant Liability Waiver and Hold Harmless Agreement contained on the Registration Form is extended to include COVID-19 exposure, infection or the monitoring of COVID-19 exposure as provided above.

29. I have read and fully understand and agree to the above stated conditions of participation in this program.

30. Electronic Signature Authorized*

    1. Yes

32. Completion of this order form will take you directly to checkout to complete your purchase.

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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field