City of Carlsbad • Parks & Recreation
Winter-Spring 2012 Registration Form PLEASE PRINT IN INK AND FILL OUT COMPLETELY Primary Adult Contact
This form, which includes the City’s Liability Waiver, has two sides and must be filled out completely, signed and returned before the activity start date or participation will not be allowed. Thank you for your cooperation.
LAST NAME ____________________________________________________________________________ FIRST NAME ____________________________________________________ ADDRESS ________________________________________________________________________________________________________________________________________________ CITY ________________________________________________________________________________________ STATE_______________________ ZIP __________________________
HM PHONE _________________________CELL PHONE ____________________________ WK PHONE _____________________________ EMAIL ____________________________ CHECK HERE IF YOU PREFER NOT TO RECEIVE OUR ELECTRONIC MAILINGS
EMERGENCY CONTACT _______________________________________________________________________ PHONE ____________________________________________________
Activity Registration ACTIVITY #
ACTIVITY NAME PARTICIPANT’S FULL LEGAL NAME (1st & Last) DOB M/F DAY TIME LOCATION START DATE
FEE
Preschool Registration
1st choice 2nd choice
Class currently enrolled in
Total Fees $ ___________
Yes! You can make a difference! My Opportunity Grants donation $ ___________ TOTAL $ ___________
Do you require any special accommodations to participate in the program you are interested in? If so, please check here. ■ Release From Liability and Indemnification (Please read before signing.)
I agree to release and hold harmless the City of Carlsbad, including its officers, employees, agents, volunteers, and elected and appointed officials; collectively “Released Parties,” from any claims, causes of action, damages, losses, liabilities, or expenses, including reasonable attorney fees and court costs, for any personal injury, property damage or death arising out of me or my child’s participation in any City of Carlsbad Parks and Recreation, program, activity and/or event, regardless of whether the personal injury, property damage or death was caused by any negligent act or omission of the Released Parties. I understand that by signing this release I am releasing all of the Released Parties from any liability resulting from me or my child’s participation in any City of Carlsbad Parks and Recreation program, activity and/ or event. I further understand and recognize that these programs, activities and events may be dangerous to me or my child and knowingly accept those risks or dangers. I understand that if I am or my child is injured, this Release will be used against me and anyone else claiming damage(s) due to me or my child’s injury in any legal action or claim. I also understand and agree that no City elected official, officer, employee, volunteer, or agent is authorized to modify this release and hold harmless agreement. I certify that I have personally read and understand this Release and hold harmless and further agree that this release shall be valid for one year from the original signature date. I may revoke this release in writing and by delivering the written revocation to the Park and Recreation Director. Revocation of this Release shall be grounds to terminate you or your child’s participation in City of Carlsbad Park and Recreation programs, activities, and events.
SIGN HERE >> SIGNATURE ______________________________________________________________ DATE ___________________________________________________ Method of Payment
SIGN HERE >> SIGNATURE ______________________________________________________________ DATE ___________________________________________________ ■ Cash ■ Check: Make checks payable to “City of Carlsbad.” ■ Charge
Get registration information, refund policy and mailing addresses for community centers at
www.carlsbadca.gov/parksandrec
Visa/MasterCard # _____________________________________ Expiration Date ____________________________________ Note: Please refer to the website for the refund policy. $20 check processing fee for refunds granted. $35 service charged for all returned checks.
PLEASE COMPLETE BOTH SIDES OF FORM 47
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