Class Registration Form

City of Huntington Beach

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. Make check payable to 'City of Huntington Beach'.

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

7. Choose one of the following:

Note:Please indicate in lower left hand corner of envelope where class is conducted.

Enclose stamped, self-addressed envelope.

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 |
=======|===============|========================|===============|=====|=====
                                                                      |
                                  Credit card fee ($1), if applicable:|_____
                                                                      |
                                                            Total Fee:|_____

Check # __________

Release and Waiver of Liability

The above named participant has my permission to participate in the activity indicated above. I realize every precaution is taken to eliminate any injuries or hazards and a competent supervisor is present; however, in the event of an injury, I hereby waive, release and hold harmless from any liability for damages or claims for damages for personal injury, including accidental death, as well as claims for property damage which may arise in connection with the above named activity, against the Supervisor, Community Services Department personnel and the City of Huntington Beach.

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)