Please print and fill out completely


Which program are you registering for? General


TRS PAYEE INFORMATION


PARTICIPANT INFORMATION LAST NAME


FIRST NAME MI


/ / / / / / / / / /


/ / / / / / / / / /


M F M F M F M F M F M F M F M F M F M F


Statistical Information (birthdate & sex of participant) is used for demographics and to customize course activities


ACTIVITY REGISTRATION FORM City of Spokane Parks and Recreation Department


LAST NAME ADDRESS FIRST NAME CITY/STATE MI ZIP


509.625.6200 Spokaneparks.org


DAY WORK OR CELL PHONE


NIGHT PHONE


EMAIL


BIRTHDATE


AGE


GENDER ACTIVITY NUMBER


ACTIVITY NAME


FEE


LIABILITY WAIVER, RELEASE & INDEMNITY AGREEMENT


I agree to release, indemnify, and hold the city, its agents, officers and employees, and School District 81, harmless from any and all liability claims, actions, judgments, damages or injuries of any kind and nature whatsoever to the participant and/or his property arising from participation in activities for which the participant is registering. I further acknowledge that I have familiarized myself with the description of the activities, understand the hazards and the participant’s personal limitations and knowingly assume all risks. I acknowledge I have read and understand this Liability Waiver, Release and Indemnity Agreement, and understand that I am waiving any claim I might have against the City or School District 81 for any harm sustained as a result of any activity for which I am registering a minor child.


______________________________________________________ Signature of Responsible Adult


How did you hear about us?  Existing customer  Inlander  Kids magazine


 TV  Spokesman


 Other_____________________


____________________ Date


May we use your photo/video image taken during activities for publicity purposes?


Yes No (circle one) Initial here ________ THERAPEUTIC RECREATION ONLY


General supervision is provided 15 minutes prior to class time and 15 minutes at end of class. If additional supervision is required there will an additional fee imposed.


Check One: Group Home/Institution In Own Home/Apartment


Dietary Precautions: Foods to Avoid: Activity Limitations/Physical problems (if any): Will you (your child) need to be reminded to take medications during program hours?


Private Home With Parent ______


Total Program Fees: $


Make checks payable to: City of Spokane Mailing Address: Spokane Parks & Recreation Department Class Registration – My Spokane 808 W. Spokane Falls Blvd. Spokane, WA 99201-3317


Credit Card Information


Card Holder’s Name VISA MC AMEX


Card No.


Exp. Date:


Yes


No


Medications Taken: PLEASE FILL OUT MEDICATION INFORMATION & WAIVER FORM Will you be using Paratransit?


Yes No If yes, what is your rider number? May 2013


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