Class Registration Form

City of La Habra

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 La Habra'.

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

7. Choose one of the following:

• Use your canceled check for a receipt.
• If you require a receipt, please mail in a self-addressed, stamped envelope with your registration form.
• Assume you have been accepted into the class, program, or trip unless advised otherwise.

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 ($1.75)  |_____
                                                                      |
                                                            Total Fee:|_____

Check # __________

or

[ ] Visa [ ] Mastercard
#_______-_______-_______-_______ Exp.Date: ____/____

Release and Waiver of Liability

Applicant hereby agrees to hold the City of La Habra, the City Council, its agents and employees free and harmless and to defend and indemnify from any and all claims for personal injury and/or property damage alleged to have been caused by the granting of such application including payment of all costs including all attorney's fees incurred by the City in defending against such a claim. I consent to emergency medical care for myself or the minor. I certify under penalty of perjury that the foregoing is true and correct.

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)