Class Registration Form

City of Buena Park

1. Make sure you've read the general information applicable to all classes.

2. Print this web page using your browser.

3. Fill in the blanks below. Please print.

4. Sign the Release Agreement at the end.

5. Fill out the credit card information or make check payable to 'City of Buena Park'.

6. Print a copy of the class description from the corresponding web page for your future reference.

7. Choose one of the following:

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.

• Only in-person registration accepted for play-school classes.
• No mail-in/phone-in accepted.
• Birth certificate required for all new students.

For your convenience, mail-in registration will begin Wednesday, December 27, 1995 for the 1st Session of classes and Monday, February 13, 1996 for the 2nd Session.

• No mail-in registration will be accepted for any play school classes.
• Mail-in registration accepted one week prior to beginning of classes.
• Walk-in registration will be accepted starting Wednesday, December 27, 1995 for the 1st Session and Monday, February 13, 1996 for the 2nd Session

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 absolve and agree to hold harmless the City of Buena Park, its employees, officers or agents from any liability which may result from my participation of that or any minor in my legal custody, in the above activity. I give permission for his/her participation in the above activity and for any necessary emergency medical treatment.

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)