Class Registration Form

City of Newport Beach

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.
Fill out the credit card information or make check payable to 'City of Newport Beach'.
Print a copy of the class description from the corresponding web page for your future reference.
Choose one of the following:

Mail In

Mail your completed registration form and payment to:

City of Newport Beach
Community Services Dept
P.O. Box 1768
3300 Newport Blvd.
Newport Beach, CA 92658-8915

Automated Phone-In

(Available only prior to class start date). Have class number and Visa or Master Card ready. 644-3153, seven days a week anytime, except Mon-Fri 8-10am and Thur 5pm-Fri 10am.

Fax-In

Include your Visa or Mastercard number on your completed form and fax to:

644-3155, Mon-Fri 8am-5pm.

Walk-In/Drop Box

Come by the Community Services Department, Mon-Fri 8am-5pm, or place complete form and payment in a sealed envelope and drop in the box located outside the office after hours.

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: (   )____-______     Social Security#: ____-___-_____


How did you hear about our programs?
[  ] Recreation Brochure
[  ] Newspaper
[  ] Flyer 
[  ] Word of Mouth
[  ] Online
[  ] Other ___________________________________________________________


=============================================================================
Participant's | Participant | Class Number  | Class Name   | 2nd Choice | Fee
Full Name     | SS#         | (and Session#)|              | Class#     |    
==============|=============|===============|==============|============|====
Steven Jones  | 500-66-8001 |8 2 4 5 . 1 0 1| Magic For Fun|   8236.101 | $50
==============|=============|=|=|=|=|=|=|=|=|==============|============|====
              |    -  -     | | | | |.| | | |              |       .    |
==============|=============|=|=|=|=|=|=|=|=|==============|============|====
              |    -  -     | | | | |.| | | |              |       .    |
==============|=============|=|=|=|=|=|=|=|=|==============|============|====
              |    -  -     | | | | |.| | | |              |       .    |
==============|=============|=|=|=|=|=|=|=|=|==============|============|====
              |    -  -     | | | | |.| | | |              |       .    |
==============|=============|=|=|=|=|=|=|=|=|==============|============|====
                                                                        |
                                                              Total Fee:|____

Check # __________   or  [ ] Visa [ ] Mastercard

                         #_______-_______-_______-_______  Exp.Date:____/____

                         Cardholder's Signature______________________________

Release and Waiver of Liability

In consideration of your accepting this registration, I hereby agree to indemnify and hold harmless the City of Newport Beach, the Newport-Mesa Unified School District and any of its officers, agents or employees from any liability or claim or action for damages resulting from or in any way arising out of the participation in the program by the person registered.

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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