2006-09-06 P&R Packet - Laserfiche WebLink

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r-------------------------------------------. please print REGISTRATION FORM separate check for each program Lino Lakes Parks and Recreation Department 600 Town Center Parkway, Lino Lakes, MN 55014 Phone: 651-982-2440 Fax: 651-982-2439 Sex_ Birthdate State (other) L-> Phone L-) Age_ Participant's Name (Last) Address Participant or Parent/Guardian Phone (h) L-J Emergency Contact (other than parent/guardian) If Participant is under 18, please print Parent/Guardian Name Participant Special Needs EmailAddress (First) City Zip (w) L-) Prg# Program Title Location Start Date Time Price VISA MasterCard _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date _ PARTICIPANT AGREEMENT: I, the participant, in consideration of my being permitted to participate in the activity, do hereby agree to hold harmless, the Lino Lakes Parks and Recreation Department, City of Lino Lakes, Centennial School District and their employees from any and all liability for any personal injury or death which may occur from my participation in this activity. This waiver includes any injuries which may result from the condition of the facilities and any improvements hereto. Participant or Parent/Guardian Signature Date L___________________________________________~ r-------------------------------------------. I please print REGISTRATION FORM separate check for each program I Lino Lakes Parks and Recreation Department I 600 Town Center Parkway, Lino Lakes, MN 55014 Phone: 651-982-2440 I I Participant's Name (Last) Address Participant or Parent/Guardian Phone (h) L-J Emergency Contact (other than parent/guardian) If Participant is under 18, please print Parent/Guardian Name Participant Special Needs EmailAddress Fax: 651-982-2439 Sex_ Birthdate State (other) L-) Phone L-) Age_ ( First) City Zip (w)L-J Prg # Program Title location Start Date Time Price VISA MasterCard _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date _ PARTICIPANT AGREEMENT: I, the participant, in consideration of my being permitted to participate in the activity, do hereby agree to hold harmless, the Lino Lakes Parks and Recreation Department, City of Lino Lakes, Centennial School District and their employees from any and all liability for any personal injury or death which may occur from my participation in this activity. This waiver includes any injuries which may result from the condition of the facilities and any improvements hereto. Participant or Parent/Guardian Signature Date L___________________________________________~ 651-982-2440 15 www.ci./ino-/akes.mn.us