Class Registration Form

City of Brea

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 Brea'.

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.

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 |
=======|===============|========================|===============|=====|=====
                                                                      |
                                           Non-Brea residents    ($5) |_____
                                                                      |
                                                            Total Fee:|_____

Check # __________

or

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

Release and Waiver of Liability

In consideration of accepting this registration, I agree to indemnify and hold harmless the City of Brea and any of their officers, agents or employees from any liability of claim or action for damages from or in any way arising out of participation in this program by the person(s) registered, except for illness or injury resulting from gross negligence or willful misconduct on the part of the City of Brea or their officers, agents, employees. In case of injury, accident or other emergency, employees of the City of Brea and/or its agents are hereby authorized to secure medical care deemed necessary as a result of accident or injury to the participant. I further agree to pay any and all costs incurred as a result of said treatment. I give permission to the City of Brea to photograph me participating in these programs, and I agree to release such a photographs to publicize City programs. Furthermore, I agree that I will not receive any compensation for such use.

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)