Class Registration Form

City of Costa Mesa

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 Costa Mesa'.

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

7. Choose one of the following:

Registrations will not be taken at class.

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 of Activity Fees:|_____
                                                                      |
                               Non-Residents (number of classes x $5):|_____
                                                                      |
                                                           Total Paid:|_____

Check # __________

or

[ ] Visa [ ] Mastercard
Holder's Name:________________________________
#_______-_______-_______-_______ Exp.Date: ____/____

Release and Waiver of Liability

I agree to waive and release the Community Services Department of the City of Costa Mesa, its officers, agents, and employees and volunteers, from and against any claims, costs, liabilities, expenses or judgments, including attorney's fees and court costs arising out of my participating in City's Programs or any illness or injury resulting therefrom, and hereby agree to indemnify and hold harmless the City from and against any and all claims, except for illness and injury resulting directly from gross negligence or willful misconduct on the part of City or its employees.

I hereby consent to treatment and all medical care deemed necessary as a result of accident or injury, I further agree to pay any and all costs incurred as a result of said treatment.
[ ]Yes - [ ]No

As part of our commitment to the 'Americans with Disabilities Act' and our participants, are there any special accommodations needed for your participation in these above mentioned activities?
[ ]Yes - [ ]No

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)