Class Registration Form

City of Yorba Linda

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 Yorba Linda'.
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:

Winter Registration
Recreation Department
P.O. Box 87014
Yorba Linda, CA 92686-8714

Walk-In

Bring your registration form and check to:

City Hall
4845 Casa Loma Ave
(Cash or checks accepted)

Mon thru Fri: 8:00am - 5:00pm

Travis Ranch Activity Center
(Checks only accepted at this location)

Mon-Wed-Fri: 8am - 5pm
Tue and Thu: 8am - 8pm
Sat: 10am - 1pm

Phone-In Charge

Not available at this time.

Mail-In Registration will be opened beginning December 11.
Walk-In Registration begins December 18

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: (   )____-______


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 |
=======|===============|========================|===============|=====|=====
                                                                      |
                                                 Processing fee($1):  |_____
                                                                      |
                                                            Total Fee:|_____

Check # __________

or

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

Release and Waiver of Liability

In consideration of your accepting this registration, I hereby agree to idemnify and hold harmless the City of Yorba Linda and its officers, agents, or employees from any liability or claim or action for damages resulting from or 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.

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

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