Class Registration Form

City of Dana Point

1. Print this web page using your browser.

2. Fill in the blanks below. Please print.

3. Sign the 'Agreement, Waiver, and Release' at the end.

4. Attach separate checks for each class, but all made payable to 'City of Dana Point Community Services Department'.

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

6. Choose one of the following:

Only the members of one family may be registered on this form. If you require a receipt, please provide a self-addressed, stamped envelope with your registration form.

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

Address:  ____________________________________________________________

City: ____________________________________________  ZIP: _____________

                              Phone Numbers

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



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

[ ] Please check the box if any/all registrants listed above are in need of additional assistance.

I have carefully read description of class(es) for which I/we are registering. In consideration for being permitted by the City of Dana Point to participate in any recration, class activity. I hereby waive, release, and discharge any and all claims for damages for personal injury, death, or property damage which I may have, or which may hereafter accrue to me, as a result of participation in said activity. This release is intended to discharge in advance the City of Dana Point, its officers, employees, and agents from any and all liability arising out of or connected in any way with may participation in said activity, even though that liability may arise out of negligence or carelessness on the part of the City of Dana Point, its officers, employees and agents. It is understood that this activity involves an element of risk and danger of accidents and knowing those risks, I hereby assume those risks. It is further agreed that this waiver, relase and assumption of risk is to be binding on my heirs and assigns. I agree to indemnify and to hold the City of Dana Point, its officers, employees, and agents free and harmless from any loss, liability, damage, cost or expense which they may incur as the result of my death or any injury or property damage that I may sustain while participating in said activity.

PARENTAL CONSENT: (to be completed and signed by parent/guardian if applicant is under 18 years of age). I hereby consent that my child(ren) named above participate in the above activity, and I hereby execute the above agreement, waiver, and release on his/her behalf. I state that said minor is physically able to particpate in said activity. I hereby agree to indemnify and hold the City of Dana Point, its officers, employees, and agents free and harmless from any loss, liability, damage, cost, or expense which they may incur as a result of the death or any injury or property damage that said minor may sustain while particpating in said activity.

I HAVE CAREFULLY READ THIS AGREEMENT, WAIVER, AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND CONTRACT BETWEEN MYSELF AND THE CITY OF DANA POINT< ITS OFFICERS, EMPLOYEES AND AGENTS AND I SIGN IT OF MY FREE WILL.

________________________________________________________________________
Signature of adult (participant, parent/guardian) for Agreement, Waiver and Release - - - - Date