Class Registration Form

City of Anaheim

Instructions

Make sure you've read the general information applicable to all classes.
Print this web page using your browser.
Fill in the blanks below. Please print.
Sign the Release Agreement at the end.
Fill out the credit card information or make check payable to 'City of Anaheim'.
Print a copy of the class description from the corresponding web page for your future reference.
Choose one of the following:

Mail In

Mail registration to:

APRCS/Registration
200 S. Anaheim Blvd.
#433
Anaheim, CA 92805

Enclose your check and self-addressed, stamped, standard size business envelope when mailing your registration.

Registration forms received without a self-addressed, stamped, standard size envelope will be delayed before processing.

Forms brought into the Recreation Dept. during mail-in registration will be processed on the following day.

Walk In

Bring completed form and check to:

Brookhurst Comm.Center
2271 W. Crescent St.
Anaheim

Phone-In/FAX Charge

When calling please have your Visa or Mastercard information ready.

FAX # 254-5223
Use white paper or print completed registration form below.

Assume you have been accepted into the class, program, or trip unless advised otherwise. Use your canceled check for a receipt. If you require a receipt, please mail in a self-addressed, stamped envelope with your registration form.

Adult Last Name: _____________________  First: __________  M.I.: _____

Address:  ____________________________________________________________

City: ____________________________________________  ZIP: _____________

Day Phone: (   )____-______            Evening Phone: (   )____-______

Emergency Contact Person: ______________________________

Emergency Phone: (   )____-______


How did you hear about our programs?
[  ] Recreation Brochure
[  ] Newspaper
[  ] Flyer 
[  ] Word of Mouth
[  ] Online
[  ] Other ___________________________________________________________


============================================================================
Class# | Class         | Participant's          | Date of Birth | Sex | Fee
       | Name          | Full Name              | (if under 18) |     |     
=======|===============|========================|===============|=====|=====
       |               |                        |               |     |
       |               |                        |    /    /     | M/F |
=======|===============|========================|===============|=====|=====
       |               |                        |               |     |
       |               |                        |    /    /     | M/F |
=======|===============|========================|===============|=====|=====
       |               |                        |               |     |
       |               |                        |    /    /     | M/F |
=======|===============|========================|===============|=====|=====
                                                                      |
                                                         Total Fee:   |_____

Check # __________

or

[ ] Visa [ ] Mastercard
#_______-_______-_______-_______ Exp.Date: ____/____

Release and Waiver of Liability

I hereby agree to indemnify and hold the City of Anaheim harmless for all liability from whatever source excepting only intentional torts on the parts of officers, agents and employees of the City of Anaheim. I am voluntarily participating in these activities with knowledge of the danger involved and hereby agree to accept any/all risks of injury.

I, THE UNDERSIGNED, CERTIFY THAT I HAVE READ AND UNDERSTAND THIS WAIVER AND RELEASE AS IT APPLIES TO MYSELF AND TO ANY MINORS FOR WHOM I AM SIGNING.

Participant Signature: ___________________________________ Date: __________
(Parent or guardian must sign for participants under 18 years of age)

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