City of Laguna Niguel Parks and Recreation Department
Activity Registration Information REGISTER TODAY !
Contact Information :
Crown Valley Community Center 29751 Crown Valley Park Laguna Niguel , CA 92677
( 949 ) 425-5100 Registration @ CityofLagunaNiguel . org
PARTICIPANT ' S NAME :__________________________ SEX : ______ DOB : ____/____/____ GRADE : _______
PARENT / GUARDIAN ' S NAME ( if participant is a minor ): ____________________________________________ ADDRESS : ________________________________________ CITY : _________________ ZIP : ___________ HOME PHONE : ________________ CELL PHONE : __________________ WORK 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 .
________________________________________________________ DATE : _____/_____/_____
( Signature ) Parent / Guardian must sign for those under 18 years of age
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PAYMENT INFORMATION :
NAME ON CARD ______________________________________________________________________________ CREDIT CARD NUMBER ________________________________________________ EXP DATE _________________ 3-DIGIT CVC CODE __________________________________________________