Class Registration Form

City of Garden Grove

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 Garden Grove'.

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

7. Choose one of the following:

Mail-In registration must be complete: including personal and class information, charge card information if applicable, signature, and date. Use your canceled check for a receipt. If you require a receipt, please mail in a self-addressed, stamped envelope with your registration form.

NOTE: The Community Services Department is not reponsible for children waiting before or after class time. Small children shall NOT remain in adult classes during instruction periods. All programs, schedules, instructors, and fees are correct to the latest possible minute before publication and are subject to change or cancellation without public notice. I hereby grant the City of Garden Grove tthe right to photograph my participation in the activities in which I will participate and use the photographs in further recreational brochures.

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 hold harmless the City of Garden Grove, its officers, agents and employees from and against any and all liabilities or claims for damages to myself, or the minor person registered to participate for which I have legal responsibilty and authority, resulting from or arising out of participation in City activities. 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. As part of our commitment to the "Americans with Disabilities Act" and our participants, are there any special accomodations 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)