Class Registration Form

City of Cypress

1. Print this web page using your browser.

2. Fill in the blanks below. Please print.

3. Sign the Release Agreement at the end.

4. Fill out the credit card information or make check payable to 'City of Cypress'.

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

6. 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: _____________

                              Phone Numbers

Day:(  )____-_____     Night:(  )____-_____     Emergency:(  )____-_____

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: ____/____

Charge Authorization Signature: ________________________

Release and Waiver of Liability

I hereby agree that I, my heirs, distributees, guardians, legal representatives and assigns, will not make claim against, sue, attach the property of, or prosecute the City of Cypress and/or the Cypress Recreation and Park District and its employees, officers, officials, volunteers, boards, departments, agents and contractors for emotional distress, bodily injury or death to myself, or property damage arising out of any actions, including negligent acts, by any employees, officers, officials, volunteers, boards, departments, agents and contractors in connection with my participations in this activity.

In addition, I hereby release and discharge the City of Cypress and its employees, officers, officials, volunteers, boards, departments, agents and contractors from all actions, cleaims or demands I, my heirs, distributees, guardians, legal representatives or assigns now have or may hereafter have, for emotional distress, bodily injury or death to myself, or property damage resulting from my participation in this activity. In case of accident or other emergency, personnel of the City of Cypress/Cypress Recreation and Park District and/or its agents, are hereby authorized to secure medical care deemed necessary as a result of accident or injury, for the participant. I further agree to pay any and all costs incurred as a reult of this treatment.

I further permit the use of activity/event photography and/or video taping for promotional 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)