2007-08-07_PR Comm Packet - Laserfiche WebLink

Home

Learn Skate Program Thursdays —November I A $8.00 processing charge will be added to all cancellations. - - - - - - - - - - - - - - - - - - KEEP THE TOP HALF OF THIS FORM FOR YOUR RECORDS_ _ Participants Name: Phone: Parent/Guardlan Name: Home Address: City: State: Zip: Gender: P M Birthday; Status: New Student_ Returning Student— Test Passed: L �2 Program # Program Name: L Does participant have any disability, allergy or special need of which we should be aware? Explain: o:E � Liability Waiver: I understand lhal participation in this activity is completely voluntary, I recognize that there are risks in my participation in 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 myself, m t ; cfl w r - my heir, executors, administrators and assigns, to release and discharge the City or Roseville, sponsor (s) of the event or activity, and their i` A officers, employees, agents, successors andfor assigns from liability for any and all injury, damage or loss that is or may arise from my participation in this activity. Data Practices Act Notice: Pursuant to the Minnesota Government Lata Practices Act, you are being V-13 to furnish certain information that is classified as private under the Act. The City coElecls such information in order to property process to requests to participate in 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 Recreation Department, and may be accessible to anyone in the Department, or In other Departments of the City. Signature: Date: E -Mail: Fee Paid Date Paid Check # By Visa or MasterCard# Exp Date The Roseville Skating Center reserves the right to cancel or adjust all session due to insufficient cnrollmcnt