Class Registration Form

City of Mission Viejo

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 Mission Viejo'.

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

7. Choose one of the following:

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 include 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/Location | Full Name              | (if under 18) |     |     
=======|===============|========================|===============|=====|=====
       |               |                        |               |     |
       |               |                        |    /    /     | M/F |
=======|===============|========================|===============|=====|=====
       |               |                        |               |     |
       |               |                        |    /    /     | M/F |
=======|===============|========================|===============|=====|=====
       |               |                        |               |     |
       |               |                        |    /    /     | M/F |
=======|===============|========================|===============|=====|=====
                                                                      |
                                                            Total Fee:|_____
                                                                      |
                                             Less 10% for passholders:|_____
                                                                      |
                                                  Total Fees Enclosed:|_____

Check # __________

or

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

Release and Waiver of Liability

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 for personal injury including accidental death, as well as from claims for property damage which may arise in conection with the above named activities, against the City of Mission Viejo and Sports Leisure Group as well as both parties officers, agents, or employees. I Further permit the use of activity/event photography and/or video for media promotion.

In case of accident or other emergency, personnel of the City of Mission Viejo and Sports Leisure Group as well as both parties officers, agents, or employees are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of said treatment.

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)

If any of the above participants have any medical or physycal condition that should be noted, please check box [ ].
If checked, please provide a written explanation with this form so that we may be better able to help should an emergency occur.

Office Use Only
Received by:_____________________ Date:________

Total Fees:______________ Amount Received:____________