UNSIGNEDAND/OR INCOMPLETE REGISTRATION FORMSwlLL NOT BE PROCESSED.

PLEASE TYPE OR PRINT IN INK.

PLEASE PRINT

last

Name of Adult Participmt or

t'r$Nme

HmeFfffi

9r'ork Phon

Address o.f Participan(s)

Citv

TOIAI
ACTTVITY CODE #

DAYS&TIME
CIASSTITLE OF CLASS

PA\MENT
NAMFJ (.)F PAKIIL'IPAN' I-

TENNIS COIJRT

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n VISA n

Address and/or Phone Number has recendy changed- Email address Participant has special needs which tequire special accommodations. Explain Enclosed firld $

tr

check/Money Order

Master Card

MasterCard orVISAAcct.

No. AG

F.rnirafionDate

Signature (for credit card authotzation only) -

I have carefi.rlh read the descrirrtion reEisterinc. and in consideratiori for beine pernitted bv the Rancho S#t ns#eation and Park Disftict t" p"tfidprt in dre'above actirity, (described in this brochure) I herebv waiig release and discharge a[ clairns for &mages for Elsonal inlury, dea*t, or propdl' arw darnage $/hich I may have, or q,{rich may hereafter accrue to mg ,r r6olt of oatticioation in said activiw. This release is intended to " in dAvanci: dre Districg ib o6cers, ernployees, and agens dischaqe

R-E-E M E NT WAIVE R, AN D RE TEASE of activities for which Uwe alt PARENTAL CONSENT: (ReEistration

shall be comnleted and signed by parent/gnrdanifap"plicant is under 18 yeirs

hereby consef,rt that

participate

-d

hereby execute the above Agreeinmg Waiver, and Releas-e on his/her behalf. I state that said rrinor is ohvsicallv able to oarticioate in said aaivitv. I herebv

in the above aaivity, and I

my son/daughter, th!

"Frg"). named abovg

agree to'i"'derxJfy and hbH

#rpby.o,

from any and all li"bilitv arising out of or connected in any way
wrdr my partiopation n'said
arise

involves an eleinent of ris[ and danger of accidents md knowing drose risks i hCIebv assurrre drose risks. it is fi-rrdrer apfeed fiat fiis waiver, release, and assumption of dsk is to be bindini on my heirs and assiqns. I a!rce to indernnifv and to hold *re Disti-ct, ib dtrs. ernpbyEes, ,rrd ug.ntr free #d harrnless ftom any loss, liabif,ty, damagrr sost -or expe$e which thqJmay iqorr as dre result qf dadl o{ ?l1y trlt\uy or.property-daqage that sald parncpant rnay sustam wrxle partrclpatmg m sard actvlty.

^.6;ty, on d",e paft of the oisdcq i6 carelessneii officers, ernplo]'&s, and agents. tt is understood *rat dris aaivity
o.it'of ndiEerrce or

even thor:Blr that liabilitir may

^d6t photogaph as they see

and agdrts fue and ha:rnless ftom any'loss, liability, damage, cost or expflse which drey may incur as a result of death ot n"y.i"i.rty or propg-ty damage_that s4d qrnor may. sustain while Darfldpaflns m satd acuvltv. I herebv qrve Defin$sron to the. pu* oistf,a"to *" h-.nb Si6i Recreanon -y, or my child's

above Dirni.g

in

offi..,o,

in their rccreatiori

brochure.

unden-tand the ohotdgraohs belons to the Rancho Simi Recreation and Park Disui&, ,trd't *il .tot *-.io. p"1r-*t of any kind-

I IIAVE CAREF'T]LLY READ THISAGREIMEi{T, WAIVE& AI\D RELEASE AI{D FI]LLY TJI{DERSTAI\D MS
CONTENTS I AM AWARE THAT THTS IS A RELEASE OF LIABILITY AIiD A CONTRAST BETWEEI\ MYSELF AI{D THE ABOYE DISTRICT,ITS OFFICERS, EMPLOYEES AIID AGENTS AND I SIGN tT OF MY PNdN WN.U

Signature of adult (participant parent/ guardian) for Agreement, Waiver and Release

Date

MAIL REGISTRATION TO:

OAK PARK RECREATION OFtrICE 1000 N. KananRoad, OakPafr-Ciltfomn91377 . Phone: (818) 865-9304. Far (818) 87+0064

DID YOU REMEMBER TO INCLUDE PAYMENT? YOU

OAK PARK RECREATION

wlLL NOT RECEIVE CONFIRMATION.