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<br /> • All Camps held at Fairview Community Center—Dance . , a 11111"°1111111. 111 11111.0 11111 1-h 6
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<br /> Stage—1910 West County Road B Enter in through the �.
<br /> gym doors and follow stage signs
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<br /> • Please bring appropriate shoes for the camp
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<br /> Register:
<br /> Online: www.cityofroseville.com/parks - By Phone: 651-792-7110 Fax: 651-792-7100
<br /> In Person: Monday- Friday 8-4:30 p.m. or By Mail: Checks payable to Roseville Parks & Recreation
<br /> Send completed registration form with check or credit card payment to:
<br /> Roseville Parks and Recreation, 2660 Civic Center Drive, Roseville MN 55113
<br /> Dancers Name: Phone Number:
<br /> Address: City/State/Zip:
<br /> Email: Date of Birth:
<br /> Program Name: Program Number:
<br /> Program Name: Program Number:
<br /> Form of payment: Cash (in person only) Check Visa Master Card American Express
<br /> Credit Card Number Exp. Date
<br /> Cardholder's Name Cardholder's Signature
<br /> Liability waiver:I understand that participation in this activity is completely voluntary.I recognize that there are risks in my participation in this activity.I agree to accept
<br /> those risks.I also agree,in consideration for my being allowed to participate in this activity,and on behalf of myself,my heir,executors,administrators and assigns,to release
<br /> and discharge the City of Roseville,sponsor(s)of the event or activity,and their officers,employees,agents,successors and/or assigns from liability for any and all injury,
<br /> damage or loss that is or may arise from my participation in this activity.Data Practices Act Notice: Pursuant to the Minnesota Government Data Practices Act,you are being
<br /> requested to furnish certain information that is classified as private under the Act.The City collects such information in order to properly process requests to participate in
<br /> activities.You may refuse to provide such information,but such a refusal may affect your ability to participate.The information will be maintained by the City Park and
<br /> Recreation Department,and may be accessible to anyone in the Department,or in other Departments of the City.
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