Class Registration Form

City of Los Alamitos

Instructions

Make sure you've read the general information applicable to all classes.
Print this web page using your browser.
Fill in the blanks below. Please print.
Sign the Release Agreement at the end.
Make check payable to 'City of Los Alamitos' and please write your Driver's License # on it.
Print a copy of the class description from the corresponding web page for your future reference.
Choose one of the following:

Mail In

Mail registration form and separate check(s) made payable to City of Los Alamitos to:

Recreation & Community Services Department
10911 Oak Street
Los Alamitos, CA 90720
Attention: Registrar
Priority registration for Los Alamitos residents will be processed, beginning Monday, Dec. 4th. Registration for non-Los Alamitos residents will be processed beginning Tuesday, Dec, 5th.

Note: Please write Driver's License # on your check.

Walk In

Walk-in registration begins Tuesday, December 11, 1995.
Office hours: 8am-5pm, Monday- Friday.
Registration not accepted for any class that has already met twice.
A drop Box located at entrance to the Community Center is provided for your convinience.

Note: Save by registering early. Fees for each class will increase by $3 for registrations received after Jan. 5th. 1996.

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 |
=======|===============|========================|===============|=====|=====
                          Registrations received after 1/5/96, add $3 |
                                     (unless meet fewer than 4 rimes):|_____
                                                                      |
                                                            Total Fee:|_____
                                                                      |
                                                          Amount Encl:|_____
                                                                      |
                                                       Receipt Number:|_____

Check # __________

If any of the above participants have any medical or physical condition that the Department should know about, please check here [ ].
Please write an explanation on the back of this form so that we may be better able to help should an emergency occur.

Release, Waiver and Assumption of Risk

In consideration of your accepting this registration, I hereby agree to indemnify and hold harmless the City of Los Alamitos, its officers, agents, or employees from any liability, claim or action for damages resulting from, or in any way arising out of participation in this program by the person(s) registered above.

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)

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