Participant’s Last Name ____________________________________________________ Parent’s Full Name _________________________________________________ Address ______________________________________________________________________ Apt.# ____________________ Day Phone ________________________ City ____________________________________________________ Zip Code _____________________ Home Phone ________________________________________ Email Address ______________________________________________________________________ Fax Number ___________________________________________
for an additional Registration form, please go to: www.UnionCity.org
Participant’s First Name M/F Birthdate Activity Code 1st choice Activity Code 2nd choice Fee
You may Register online at www.UnionCity.org
I wish to make a donation to the Support Our Kids (SOK) Fund: ________________________________________________________________________
For refund make check payable to: _________________________________________________ Do participants live within New Haven Unified School District? I hereby authorize the use of my credit card: Type of card (circle one):
Mastercard, Visa, Discover Cards (We do not accept american express)
Please provide all of the following information if you are paying by credit card. If you do not fill it out completely, we may not be able to register the participant in the program you are trying to register for. If you have any questions, please contact any of our centers.
Name on Card ________________________________________________________________________________________________________________________ Card number _____________________________________________________________
Expiration date (month/year) ________________/ _____________
Credit Card Verification Number (CID)____________________________________ Visa and Mastercard: The CID number is the last 3 digits of the number shown in the signature box on the back of your card. Billing address:________________________________________________________________________________________________________
City:____________________________________State____________________ Zip Code____________________________________________ I the undersigned, agree to indemnify and hold harmless the City of Union City from any loss or liability which is alleged to have resulted from my participation in this pro- gram. I have read and understand the activity description listed in the Union City Leisure Services Department Activity Guide, and I comprehend all the risks involved by participating in that activity. I hearby give my dependents permission to participate in the activities indicated and absolve the City of Union City, its employees, volunteers, contractors and officers from liability. I also grant full permission to any and all of the foregoing to use my name and any photographs, videographs, motion pictures or re-
cordings for any publicity and promotion purposes without obligation or liability to me. I understand that no refunds or transfers will be given on or after the first class. sIGnaTURe____________________________________________________________________________
Parent Guardian Participant
DaTe __________________________ Do you have any special needs that require specific accommodations so you can fully enjoy one of our classes or facilities? If yes, please call 675-5329 for more information. YES, I have special needs that might require special accommodations.
For Office Use Only ________Cash Check # ________Credit Card Processed _______________ Processed by ________________________Date ____________Class_______________
REGISTRATION DATES Winter/ spring 2011
• Online Fax Registration starts, Nov 22 • Mail-in/ Fax begins Nov 22, 2010 • Walk-in registration, Jan 4, 2011 • Winter Classes: Jan 10 - March 20 • spring Classes: March 28 - June 12
Holidays: MLK Jr. Day: Mon, Jan 17 Presidents Day: Mon, Feb 21 Memorial Day: Mon, May 30
You may Register online at www.UnionCity.org
Union City Leisure Services Registration, 34009 Alvarado-Niles Rd, Union City, CA 94587 (no walk-in registration will be accepted at this address.)
Please note that all City offices and community centers, except for the Sports Center, will be closed for the holiday furlough from Thursday, December 23 through Friday, December 31. Offices and centers will reopen on Monday, January 3, 2011. Online registration is available during that period at www.UnionCity.org
HOW TO ReGIsTeR 1) Locate the code number of the activity for which you wish to register. Select a second choice in case the first activity is full.
2) Fill out the registration form completely. Print clearly and include a signature.
3) Make check payable to the City of Union City or fill in the information to use your credit card (Visa, Mastercard, or Discover Card). Please include the Verification Numbers, CID, on the back of your card. Minimum of $25.00 purchase to use Credit Card.
3a) To register by fax, fill out credit card information with a return fax # if you want a confirmation.
Holly Community Center • (510) 471-6878 Kennedy Community Center • (510) 429-6730 Ruggieri Senior Center • (510) 477-0317 • UC Sports Center • (510) 489-8620 Note: Faxed registrations will receive confirmations by fax. Please indicate that you would like a confirmation receipt otherwise we will not send one. Please be sure to include your fax number.
Cl ick Here To Register Onl ine
4) Enclose a legal size, self-addressed, stamped envelope if mailing in your registration. Confirmation will be sent within three weeks. You will not receive confirmation unless a self-addressed, stamped envelope is included.
5) You can register online 24 hours a day, 7 days a week. If you do not have an account with Union City, and wish to create one, you may go online or come to one of the Community Centers to create one.
6) If you are registering online, please make sure you have an account with us first. If you wish to create an account, please contact any of the community centers and we can help you create one.
Re g i s t e r On l i n e a t www.UnionCi ty.org
ReGIsTRaTIOn fORM & DaTes
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