Registration Form
NAME:
HOME PHONE: ( ) WORK PHONE: ( ) CELL: ( )
STREET ADDRESS:
CITY: STATE: ZIP:
EMAIL ADDRESS:
By giving us your email we can notify you of program changes, cancellations, and new programs that will interest you. Your email address will not be shared with any other organization. You will not be spammed.
EMERGENCY CONTACT: EMERGENCY CONTACT PHONE: ( )
o Check this box to opt out of program updates via email.
CLASS # PARTICIPANT NAME (FIRST, LAST) CLASS NAME COST
SUBTOTAL
PAYMENT INFORMATION
UCARE ID#
UCARE DISCOUNT
Register now, pay later—see page 14
TOTAL COST
o CHECK (Payable to “District 622”—wil be handled as a one-time electronic fund transfer or draft)
o VISA
o MASTERCARD
CARD NUMBER: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ EXP. DATE: ____ / ____
o AMERICAN EXPRESS
o DISCOVER
SIGNATURE:
DATE:
PERMISSION, RELEASE, PHOTO AND LIABILITY WAIVER
I, a participant, in consideration of my being permitted to participate in the ISD 622 Community Education activity, do hereby agree to hold
harmless the ISD 622 School District and their employees, board members or agents from any and all liability for any personal injury, death, loss of
property or any other circumstance which may occur from my participation in this activity. This waiver includes injuries which may result from the
condition of the facilities and any improvements hereto. I authorize ISD 622 to disclose to the district’s insurer, attorney, staff, coaches, participants
and other personnel involved in this program the following information: name, address, email address and telephone number. This information
shall be used only for the purpose of program administration.
In addition, due to the highly contagious nature of the current COVID-19 virus outbreak and potentially any other virus that can be contracted from
both symptomatic and asymptomatic people, North St. Paul-Maplewood-Oakdale School District assumes no responsibility for the contraction
of any illness as a result of your participation in this class or related class activities. All participants are required to comply with social distancing
expectations. Failure to do so could result in removal from the program and the premises. The school will not be responsible for determining
whether or not any participant has or does not have COVID-19 or any other illness before, during or after this class or class activity. Anyone having
any illness is required to not attend class. It is the school district’s recommendation that during the COVID-19 pandemic that the participant consult
their doctor before participating and follow the CDC guidelines related to social distancing and wearing personal protective equipment.
I also give my consent for ISD 622 Community Education to use any photo or video tape taken of my child (or person I am responsible for as
guardian), or myself for future promotional or marketing materials. If I do not wish to be photographed or video taped, I will notify ISD 622
Community Education in writing.
By choosing yes you signify your acceptance of this consent as parent/guardian (if participant is a minor) or as the adult participant.
This permission, release, photo and liability waiver applies even if the undersigned asserts the program was at fault for not taking greater
precautions to manage exposure or infection from COVID-19 and the pandemic. Participants and their families assume the risk of illness and injury,
as outlined in this document.
I HAVE READ AND UNDERSTAND AND ACCEPT ALL OF THE ABOVE STATEMENTS AND ACCEPT FULL RESPONSIBILITY AS DESCRIBED.
PARTICIPANT SIGNATURE:
District 622 Community Education | www.isd622.ce.eleyo.com | 651-748-7250
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