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Beginner and intermediate skateboarders are <br />invited to sign up to learn techniques and secrets <br />rd <br />from the 3 Lair Demo Team and staff of <br />instructors. <br /> Program # Dates Time <br /> 9100.560 June 11-15 9:00-12:00pm <br /> 9100.561 July 16-20 9:00-12:00pm <br /> <br />All camps are Monday - Friday <br />Price: $160.00/week <br />Ages 6-13 <br /> <br /> <br />Every camper receives: <br />-Certificates of Completion <br />-Promotional products from Skateboard Companies <br />rd <br /> <br />that support 3 Lair <br />Register online: http://www.cityofroseville.com/skatingcenter <br /> <br />Participants Name: Phone: <br /> <br />Parent/Guardian <br /> <br /> <br />Name <br />: <br /> <br />Home Address: City:State:Zip: <br /> <br /> <br /> <br /> <br /> <br />GENDER (circle one): F M BIRTHDATE:____________ PROGRAM #:______________________________ <br /> <br /> <br />Emergency Contact:__________________________________ Emergency Phone #_________________________ <br /> ______ ___________________ <br />Does participant have any disability, allergy or special need of which we should be aware? Explain: <br /> <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 <br /> <br /> <br />accept 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 <br />and assigns, to release and discharge the City or Roseville, sponsor (s) of the event or activity, and their officers, employees, agents, successors and/or assigns from <br />liability for any and all injury, damage or loss that is or may arise from my participation in this activity. <br /> <br />Data Practices Act Notice: Pursuant to the Minnesota Government Data Practices Act, you are being requested to furnish certain information that is classified as <br /> <br />private under the Act. The City collects such information in order to properly process requests to participate in activities. You may refuse to provide such information, <br />but such a refusal may affect your ability to participate. The information will be maintained by the City Park and Recreation Department, and may be accessible to <br /> <br />anyone in the Department, or in other Departments of the City. <br /> <br />Signature: Date: E-Mail: <br /> <br />Fee PaidDate PaidCheck #By <br /> <br />Visa or MasterCard#Exp Date <br /> <br />