**Not affiliated with Dist 428** “Sports of All Sorts!” After School Program DeKalb Park District is partnering with NIU sports clubs to offer a sports-oriented afterschool program exclusively for middle school students. This high-energy program gets kids moving in a wide variety of traditional and non-traditional sports, regardless of their skill level. This program encourages the development of a healthy, active lifestyle through sports participation. Sports & Recreation Center, 1765 S. Fourth St., DeKalb 6th/7th/8th graders Mon/Wed/Fri 3:00-4:30pm Open gym time available for participants before and after the program. Nov 17th - Dec 19th (program held on full school days) $35 resident/$45 non-resident Drop in (daily) $4 resident/$6 non-resident *Scholarship assistance available to residents that qualify* For additional information contact... Jeff Myles, Athletic Coordinator (815) 758-7756 jmyles@dekalbparkdistrict.com PLEASE CUT HERE Sports of All Sports Registration Form Registration forms and payment (cash/check/CC) should be submitted at the Sports & Rec Center (1765 S. 4th Street). Phone registration is also available with credit card (Visa/MC/Discover). Please call (815)758-7756 to register or if you have questions. Participant Information Participant Name: ___________________________________________ Date of Birth: _____________ Male____ Female____ Please describe any health problems or special circumstances that program coordinators should be aware of: ____________________________________________________________________________________________________________ Parental Information Mother’s/Guardian’s Name____________________________________ Phone____________________ H / W / C D.O.B.________ Father’s Name______________________________________________ Phone____________________ H / W / C D.O.B.________ Street Address:______________________________________________ __________ City:_________________________ Email Address (s)__________________________________________________________________________ Please sign wavier on back side... In Case of Emergency Contact Name___________________________________ Phone_______________________ Top 10 reasons to join us for Sports of All Sorts After School Program 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. NIU students think you are cool and want to hang out with you. It’s too early to go home for the day. No teachers allowed! More time for hanging out with your friends (so make sure they sign up too). NIU athletes…need we say more? We won’t make you do your homework during the program. Our cool indoor turf. You’ve probably played basketball or soccer, but have you ever tried quidditch, ultimate Frisbee, field hockey, or Brazilian Ju-jitsu? Your parent won’t be here. This is the start of new middle-school programs at the Park District. Be a part of it and have input on where we go from here. PLEASE CUT HERE Medical Release In the event of an emergency, I authorize the DeKalb Park District to secure any/all necessary medical attention from any accredited hospital and/or ward and further agree that I will be responsible for any and all medical services rendered. Waiver, release of all claims and hold harmless agreement for DeKalb Park District Please read this form carefully and be aware that, in signing up and participating in Park District programs, you will be waiving and releasing all claims for injuries, arising out of participation, which you or the above participant might sustain. The terms, “I,” “me,” and “my” also refer to parents or guardians as well as the participants in the programs. In registering for the Park District programs, you are agreeing as follows: As a participant, I recognize and acknowledge that there are certain risks of physical injury, and I agree to assume the full risks of any injuries, including death, damages or loss which I may sustain as a result of participating, in any manner, in any and all Park District activities. I further recognize and acknowledge that all athletic activities involving strenuous exertion or potential body contact are hazardous recreational activities and involve substantial risks of injury. I agree to waive and relinquish any and all claims I may have as a result of participating in programs against the DeKalb Park District, any and all other participating or cooperating governmental units, any and all independent contractors, officers, agents, servants and employees of the governmental bodies and independent contractors, and any and all other persons and entities, of whatever nature, that might be directly or indirectly liable for any injuries that I might sustain while participating. (The parties described in the preceding sentence are referred to as “released parties” in the remainder of the Agreement.) I do hereby fully release and discharge the DeKalb Park District, and any and all other released parties, from any and all claims resulting from injuries, including death, damages and losses sustained by anyone, and arising out of, connected with or in any way associated with my conduct and the activities of Park District programs. I further understand and agree that the terms such as “participation,” “programs” and “activities,” referred to in this Agreement, include all exercises and physical movements of any nature while I am participating in Park District programs, and further include the provision of or failure to provide proper instructions or supervision, the use and adjustment of any and all machinery, equipment and apparatus, and anything related to my use of the services, facilities or premises of the Park District. I have read and fully understand this Waiver, Release and Hold Harmless Agreement. I further understand that any advisements or warnings of the particular risks of participation that I subsequently receive will be incorporated by reference into and become a part of this Agreement. I have carefully read the insurance liability waiver and understand that my signature is required below in order to participate in DeKalb Park District programs. Waiver is effective for one year from the date of signature. PARTICIPATION WILL BE DENIED if the signature of parent/guardian and date are not on this waiver _______________________________________________________________________________________________________________________ PARTICIPANT’S PARENT/GUARDIAN SIGNATURE DATE STAFF INITIALS