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City of Roseville Parks and Recreation
<br />Register in person or by mail at 2660 Civic Center Drive, Roseville, MN 55113
<br />or Online: www.cityofroseville.com/parks
<br />Participant:_____________________________________Phone: (h)_________________ (w)_____________________
<br />Address:__________________________________________________ City:__________________________State:_____
<br />Zip:_____________
<br />Gender: F M Birthdate:__/___/___ Fall Grade _____
<br />Parent Name:_________________________ E-Mail:__________________________________________________
<br />Does the participant have any special needs, disability, or allergy that the staff should be aware of? Yes No
<br />Please explain:______________________________________________________________________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />___Check ___Cash___Visa___MC Name on Card:____________________________________________________
<br />Credit Card #:__________________________________________________________ Expiration:___/_____
<br />Tennessen Warning:
<br /> The information requested on the registration form will be used to verify eligibility and determine staff, faculty and
<br />equipment needs. You/your child’s name, age, grade level, address, telephone number and health information will be provided to appropriate
<br />City staff, volunteers, City Attorney, insurer and auditor. Although you are not legally required to disclose the information, failure to do so
<br />will prevent you/your child from participating in the program.
<br />Liability Waiver:
<br />I understand that participation in this activity is completely voluntary. I recognize that there are risks in my participation in
<br />this activity. I agree to accept those risks. I also agree, in consideration for my being allowed to participate in this activity, and on behalf of
<br />myself, my heir, executors, administrators and assigns, to release and discharge the City of Roseville, sponsors of the event or activity, and
<br />their officers, employees, agents, successors and/or assigns from liability for any and all injury, damage or loss that is or may arise from my
<br />participation in this activity.
<br />City of Roseville Parks and Recreation
<br />Register in person or by mail at 2660 Civic Center Drive, Roseville, MN 55113
<br />or Online: www.cityofroseville.com/parks
<br />Participant:_____________________________________Phone: (h)_________________ (w)_____________________
<br />Address:__________________________________________________ City:__________________________State:_____
<br />Zip:_____________
<br />Gender: F M Birthdate:__/___/___ Fall Grade _____
<br />Parent Name:_________________________ E-Mail:__________________________________________________
<br />Does the participant have any special needs, disability, or allergy that the staff should be aware of? Yes No
<br />Please explain:______________________________________________________________________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />Prog #__________________ Program Name:_________________________________ Total Fee:______________
<br />___Check ___Cash___Visa___MC Name on Card:____________________________________________________
<br />Credit Card #:__________________________________________________________ Expiration:___/_____
<br />Tennessen Warning:
<br /> The information requested on the registration form will be used to verify eligibility and determine staff, faculty and
<br />equipment needs. You/your child’s name, age, grade level, address, telephone number and health information will be provided to appropriate
<br />City staff, volunteers, City Attorney, insurer and auditor. Although you are not legally required to disclose the information, failure to do so
<br />will prevent you/your child from participating in the program.
<br />Liability Waiver:
<br />I understand that participation in this activity is completely voluntary. I recognize that there are risks in my participation in
<br />this activity. I agree to accept those risks. I also agree, in consideration for my being allowed to participate in this activity, and on behalf of
<br />myself, my heir, executors, administrators and assigns, to release and discharge the City of Roseville, sponsors of the event or activity, and
<br />their officers, employees, agents, successors and/or assigns from liability for any and all injury, damage or loss that is or may arise from my
<br />participation in this activity.
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