Class Registration Form

City of Placentia

Instructions

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 Placentia'.
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 to:

City of Placentia
Recreation and Human Services
401 E. Chapman Avenue
Placentia, CA 92670

Drop-Off

You can bring your registration between 7:30am and 5:30pm Monday through Friday to:

City of Placentia
Recreation and Human Services
401 E. Chapman Avenue
Placentia, CA 92670

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: _____________

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 |
=======|===============|========================|===============|=====|=====
                                                                      |
                                                            Total Fee:|_____

Check # __________

All fees are nontransferable

Release and Waiver of Liability and Indemnity Agreement

In consideration of your accepting this registration, I hereby agree to indemnify and hold harmless the City of Placentia and any of its officers, agents or employees from any liability, claim or action for damages resulting from or in any way arising out of the participation in this 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.

Signature: ___________________________________ Date: __________
(Parent or guardian must sign for participants under 18 years of age)

[ ] Parent . . . . [ ] Guardian . . . . [ ] Participant

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