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e <br />Learn to Skate Program <br />�.i� 1, = `�' •g,. f <br />REGISTER. ONLINE a) vrvvw.cityofroseville.com/s%atingcenter <br />Registration Begins December 3, 2007 <br />THERE ARE NO PROVISIONS rOR MAKE UP CLASSES! <br />An $8.00 processing charge will be added to all cancellations. <br />KEEP THE TOP HALF OF THIS FORM FOR YOUR RECORDS. <br />Participants Name.- <br />Phone: Parent/Guardian <br />Name: <br />Home Address: <br />City: State: Zip: <br />Gender( circle): F M Birthdate: Status : New Student Returning Student <br />Program # Program Name: Test Passed: <br />Does participant have any disability, allergy or special need of which we should be aware? Explain: <br />� cn <br />(13Liability <br />LO <br />Waiver: I understand that participation in this acfivity is completely voluntary. I recognize that there are risks in my participation in this <br />Zactivity. <br />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, <br />my heir, executors, administrators and assigns, 10 release and discharge the Cify or Roseville, sponsor (s) of the event or activity, and their <br />? m ru <br />officers, employees, agents, sucoessars and/or assigns from liability for any and ail injury, damage or loss that is or may arise from my <br />t� <br />a) <br />or <br />participation in this activity. Data Practices Act Notice: Pursuant to the Minnesota Government Data Practices Act, you are being requested <br />re c`Do <br />;" <br />to furnish certain information that is classified as private under the Act. The City collects such information in order to properly process <br />- <br />requests to participate in activities. You may refuse to provide such information, but such a refusal may affect your ability to participate. The <br />information will be maintained by the City Park and Recreation Department, and may be accessible to anyone in the Department, or In other <br />Departments of the City. <br />Signature. <br />Date: E -Mail: <br />Fee Paid <br />Date Paid Check # By <br />Visa or MasterCard #: <br />Exp Date <br />The Roseville Skating Center reserves the right to cancel or adjust any session due to insufficient enrollnnent <br />