| RARA Program Registration Form |
| Please print this registration form and use it to register
for any class in the current brochure, unless otherwise noted in the class description. |
| PARENT NAME:
________________________________________ |
City : (__)Rochester (__)Rochester Hills |
| ADDRESS : ____________________________________________
|
(__)Other ______________________ |
| DAYTIME PHONE : _____________________________________
|
Zip : (__)48306 (__)48307 (__)48309 |
| WORK PHONE : ________________________________________
|
(__) Other ______________________ |
| EMERGENCY CONTACT :
________________________________
& CONTACT PHONE : ____________________________ |
| EMAIL ADDRESS OF ADULT (OPTIONAL) :
___________________________________________________
|
PARTICIPANT
First & Last |
BIRTH DATE* |
SCHOOL* |
GRADE* |
CLASS # |
PROGRAM NAME |
PROGRAM FEE |
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| * Information needed for children only
|
| DESCRIBE ANY SPECIAL ACCOMODATIONS OR NEEDS:
___________________________________________ |
| METHOD OF PAYMENT: CHECK # _________________ |
|
OR MC/VISA:
__________________________ EXP. DATE: _____________ |
| |
| YOUR NAME AS IT APPEARS ON YOUR CARD (PLEASE
PRINT) : _______________________________ |
| I HAVE READ AND UNDERSTAND THE NATURE OF THE
PHYSICAL DEMANDS OF THIS ACTIVITY AND THE POLICIES SET FORTH BY R.A.R.A. I
HAVE NOTED ABOVE ANY MEDICAL OR PHYSICAL CONDITIONS WHICH MIGHT AFFECT
PARTICIPATION. I THEREFORE RELEASE ANY AND ALL RIGHTS OR CLAIMS FOR
DAMAGES AGAINST THE ROCHESTER AVON RECREATION AUTHORITY AND ALL
INDIVIDUALS ASSISTING IN THE INSTRUCTION OR CONDUCTION OF THEIR ACTIVITES,
FOR ANY AND ALL INJURIES, LOSS OR DAMAGE SUFFERRED BY MYSELF OR THE
PARTICIPANT AT OR IN ANY WAY CONNECTED WITH THESE INJURIES. |
| ______________________________________________________________________
|
| SIGNATURE OF PARTICIPANT (OR PARENT OR GUARDIAN
IF YOUTH) |
<------------------------------------------------------------------------------------------------------->
OFFICE USE ONLY |
| REGISTRATION TAKEN BY: _________
|
RES. (__) NON. RES. (__)
|
| DATE : ___________ |
AMOUNT PAID: _________________ |
RECEIPT NUMBER: ___________________
| |