Form Center

2. Police Outreach Program Registration Form
4. Child's Full Name*
5. Date of Birth*
6. Gender*
8. School*
9. Grade*
10. Age*
12. Medical or dietary restrictions?*

    1. Yes
    2. No
13. If "yes", please explain
15. Second Child's Full Name
16. Date of Birth
17. Gender
19. School
20. Grade
21. Age
23. Medical or dietary restrictions?

    1. Yes
    2. No
24. If "yes", please explain
26. Third Child's Full Name
27. Date of Birth
28. Gender
30. School
31. Grade
32. Age
34. Medical or dietary restrictions?

    1. Yes
    2. No
35. If "yes", please explain
37. Do any of the children need special accommodations?

    1. Yes
    2. No
38. If "yes", please explain
40. Are you okay if your children walk home?

    1. Yes
    2. No
42. Parent/Legal Guardian*
44. Address*
46. City*
47. State*
48. Zip Code*
50. Cell Phone Number (Test Message Alerts)*
51. Home Phone Number
53. Emergency Contact (if the parent/legal guardian is not available)*
55. Phone Number*
56. Does the emergency contact have permission to drop off/pick up your children?*

    1. Yes
    2. No
58. Liability Waiver and Photo Release
60. You are solely responsible for determining if your minor child/ward or you 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. Please read this form carefully and be aware that in signing up and participating in this program/activity, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which your minor child/ward or you 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.) Waiver & Release of All Claims and Assumption of Risk 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 waiver and relinquish all claims my minor child/ ward or I may have (or accrue to my child/ward or me) as a result of participating in this program/activity against the , including its officials, agents, volunteers and employees. I do hereby fully release and forever discharge the Prospect Heights Police Department from any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to my minor child/ward or me and arising out of, connected with, or in any way associated with this program/activity.
62. I hereby authorize and give my consent to the Prospect Heights Police Department to photograph/video my children (or me), and without limitation, to use such photographs/video in connection with promoting/advertising the services, programs, and facilities of the Police Department without consideration of any kind, including, but not limited to, the City of Prospect Heights website and Police Department sponsored social media site(s).
64. Child's Name*
66. Child's Name
68. Child's Name
70. Adult or Parent's Name (18 years or older or Parent/Guardian)*
72. Date*
74. If you have multiple children please provide a photo for each child
76. Upload Picture of Child Here*
77. Upload Picture of Child Here
78. Upload Picture of Child Here
80. By checking the box below and submitting this form, I agree that my electronic signature is the legal equivalent of my manual signature. I understand that by signing electronically, I am acknowledging and agreeing to the terms, conditions, and policies outlined in this form. I also affirm that all information provided is true and accurate to the best of my knowledge.*

    1. Agree
82. Notes
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field