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r1*'111 14 14 <br /> T E ����) nnl l�����aIlD1N111111111111111���i�111111111��111 <br /> G J I D/A 1 T 10 1,df l 1,l:.r, <br /> Parks&.IRecreation Department <br /> Youth J'DcanCIV Pro Sam <br /> Bandy is a fast paced combination of soccer and hockey played on ice without checking. Boys and girls in <br /> grades K-12 who can skate are invited to participate. <br /> Equipment required: skates, helmet with face mask, mouth guard, shin pads, elbow pads, bandy stick <br /> (purchase through MN Youth Bandy). All Bandy players receive a jersey. <br /> Call Nancy Nelson @ 651-484-0840 for information. Register by November 10. Late registrations <br /> accepted if space is still available. <br /> .................. <br /> x� <br /> o <br /> i r , <br /> i <br /> r <br /> /r ,rm nf rf <br /> l!y <br /> ii <br /> l , l <br /> V <br /> h <br /> i <br /> o <br /> rr a <br /> r; <br /> � '�" %/%//�iiai i/1 „ ill N ,, iarrrrrrMd+vwinoaan N(d14 <br /> ' 1 <br /> g. <br /> Program# Level Day Time Dates <br /> 9100.464 Beg. Fridays 5:30 - 6:30 pm 11/19/09 - 3/4/2010 <br /> 9100.465 Int. Fridays 6:30 - 7:30 pm 11/19/09 - 3/4/2010 <br /> 9100.466 Adv. Sundays 4:30 - 6:30 pm 11/19/09 - 3/6/2010 <br /> *No class December 24, 26 or 31 <br /> Fee: $95 Regular, $85 Roseville Resident <br /> _ _ _ _ _ _ _ _ __ _ _ _ _ Register_Online @_www.cityofroseville.com/skatingcenter <br /> _ _ _ _ _ _ _ _ _ _ _ <br /> 2010 - 2011 Youth Bandy <br /> PARTICIPANT NAME: PARENT/GUARDIAN NAME: <br /> ADDRESS: CITY: STATE: ZIP: PHONE: <br /> EMAIL ADDRESS: <br /> GENDER(circle one): F M BIRTHDATE: PROGRAM#: <br /> L M <br /> 0 ; Does participant have any disability,allergy orspecial needs? Explain. <br /> � Lo <br /> Liability Waiver: I understand that participation in this activity is completely voluntary. I recognize that there are risks <br /> Z .�' N in my participation in this activity. I agree to accept those risks. I also agree, in consideration for my being allowed to <br /> 0 ti participate in this activity, and on behalf of myself, my heir, executors, administrators and assigns,to release and dis- <br /> h � charge the City or Roseville, sponsor(s)of the event or activity, and their officers, employees, agents, successors and/ <br /> or assigns from liability for any and all injury, damage or loss that is or may arise from my participation in this activity. <br /> Data Practices Act Notice: Pursuant to the Minnesota Government Data Practices Act, ou are being requested to <br /> Y 9 re q <br /> furnish certain information that is classified as private under the Act. The City collects such information in order to prop- <br /> erly process requests to participate in activities. You may refuse to provide such information, but such a refusal may <br /> affect your ability to participate. The information will be maintained by the City Park and Recreation Department, and <br /> may be accessible to anyone in the Department, or in other Departments of the City. <br /> Signature: Date: Email: <br /> Amount Paid: Cash: Check#: Received By: <br /> Visa or MasterCard#: Expiration Date: <br />