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
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SUBTOTAL |
PAYMENT INFORMATION |
UCARE ID # |
UCARE DISCOUNT |
Register now , pay later — see page 14 |
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CHECK ( Payable to “ District 622 ”— wil be handled as a one-time electronic fund transfer or draft ) |
TOTAL COST |
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VISA |
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MASTERCARD
AMERICAN EXPRESS
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CARD NUMBER : ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ EXP . DATE : ____ / ____ |
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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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