Summer 2022 Recreation Brochure Summer 2022 | Page 38

REGISTRATION FORM
City of Laguna Niguel Parks and Recreation Department

REGISTRATION FORM

ONE FORM PER PERSON REQUIRED
Contact Information : Crown Valley Park
29751 Crown Valley Parkway Laguna Niguel , CA 92677
( 949 ) 425-5100 Registration @ CityofLagunaNiguel . org
PARTICIPANT ’ S NAME :______________________________________________________ SEX _____ D . O . B _____/_____/_____ GRADE _________ PARENT / GUARDIAN NAME ( if participant is a minor ):__________________________________________________________________________ ADDRESS ________________________________________________________________ CITY ________________________ ZIP _______________ HOME PHONE ( _____ ) ______ - __________ WORK PHONE ( _____ ) ______ - _________ CELL PHONE ( _____ ) ______ - ___________ EMAIL ADDRESS ___________________________________________________________ @____________________________________________ EMERGENCY CONTACT ( other than parent )________________________________________________ PHONE ( _____ ) ______ - ____________
MEDICAL INFORMATION _________________________________________________________________________________________________ If you need special assistance , please contact the Parks and Recreation Department at least one week prior to the start of activity .
ACTIVITY # NAME OF ACTIVITY DAY / TIME CHECK # FEE
I voluntarily agree to have myself or my child participate and I realize that every precaution is taken to eliminate any injury or hazards to myself or my child , and that a competent supervisor is present ; however , in the event of any injury to myself or my child , I hereby waive , release and hold harmless from any liability for damages or claims for damages for personal injury , including accidental death , as well as from claims for personal property damage which may arise in connection with the program , against the City of Laguna Niguel and all it ’ s officers , agents and employees .
I give consent to any X-Ray examination , anesthetic , medical or surgical diagnosis tendered under the general or special supervisor of any member of the medical staff and emergency room staff licensed under the Medicine Practice Act or a dentist licensed under the Dental Practice Act or the staff of any acute General hospital holding a license to operate from the California Department of Public Health . It is understood that this authorization is given in advance of diagnosis , treatments , or hospital care being required but is given to provide the aforementioned medical / dental personnel authority to render care as they deem advisable . It is understood that efforts shall be made to contact the undersigned prior to rendering treatment , but that treatment will not be withheld if the undersigned cannot be reached .
I permit the use of activity / event photography and / or video of my child or myself for LN Parks & Recreation media promotion .
I HAVE READ AND UNDERSTAND THIS RELEASE FROM LIABILITY AND THE CANCELATION / REFUND POLICY .
________________________________________________________________________________ ( Signature ) Parent or Guardian must sign for those under 18 years of age
Date _________/_________/_________
PAYMENT INFORMATION :
NAME ON CARD _____________________________________________________________________________________________________
CREDIT CARD NUMBER __________________________________________________________ EXP DATE _________/_________/_________
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3-DIGIT CVC CODE ______________