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TeenScene_Fall2019_web

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Cary Parks, Recreation & Cultural Resources page 23 Town of Cary Parks, Recreation and Cultural Resources Department Program Registration Form Main Contact Last Name _______________________________________________ First Name _______________________________________________ q Male q Female q Adult DOB______ /______ /______ Are you a Cary Resident? q Yes q No Mailing Address _____________________________________________________________________________________________________ City _____________________________________ ST ___________ Zip _______________ Home Phone __________________________ Work Phone __________________________ Mobile Phone ___________________ *Email _____________________________________ 1st Emergency Contact ___________________________________ ___________ Phone _____________________________________ Non Household Emergency Contact _______ Phone ____________________________________________________________________ Registration Receipt: I would like my receipt (please check one) q emailed (valid email address required) q printed/mailed * By providing my email address I agree to receive email communication from Town of Cary. Participant #1 Information Participant #1 Name _____________________________________________________________________________ q Male q Female DOB______ /______ /______ Rising Grade (Summer Camps) ____________ Is this person allergic to anything? _________ Currently taking any medications? ________ Have any special needs? _________ If answered yes to any of these questions, please explain in detail: _________________________________________________________ _____________________________________________________________________________________________________________________ Programs are provided for people of all abilities. If you need a reasonable modification, please check YES below and complete the registration at least two weeks prior to the start of the program/class. Each request will be assessed in compliance with ADA. q YES Course Code Program Name Location Date Time Fee 1 _______________ _______________________________ _________________________________ __________ ___________ ________ _______________ _______________________________ _________________________________ __________ ___________ ________ Participant #2 Information Participant #2 Name ___________________________________________________________________________ q Male q Female DOB______ /______ /______ Rising Grade (Summer Camps) ____________ Is this person allergic to anything? _________ Currently taking any medications? _________ Have any special needs? _________ If answered yes to any of these questions, please explain in detail: _______________________________________________________ _______________________________________________________________________________________________________________ Programs are provided for people of all abilities. If you need a reasonable modification, please check YES below and com- plete the registration at least two weeks prior to the start of the program/class. Each request will be assessed in compliance with ADA. q YES Course Code Program Name Location Date Time Fee 1 ______________ _____________________________ _______________________________ _________ __________ ________ ______________ _____________________________ _______________________________ _________ __________ ________ Payment Information MAKE CHECKS PAYABLE TO "Town of Cary" 2 Scholarship Donation $ _______________ TOTAL AMOUNT DUE $ _______________ WAIVER I, for myself or as parent or guardian, hereby assume all the risks and hazards incidental to the conduct of the activities and transportation to and from the activities. I release, absolve, and indemnify the Town of Cary, employees of the Town, volunteers, contractors and/or sponsors from all risks and hazards associated with the activities and in the event of injury, do expressly waive all claims against them. I understand that no insurance coverage is provided by the Town of Cary Parks, Recreation and Cultural Resources Department. By registering for this program, I understand and agree that if a program in canceled or a portion unable to be completed due to inclement weather or other unforeseen circumstances, I will receive an appropriately prorated credit on my account for the uncompleted portion of the program. Further, I understand that I may withdraw from a class that has not been cancelled with written request at least one week before the scheduled start of the class. Cancellations will be credited or refunded in full and withdrawals with at least one week notice will be credited in full or refunded with a $5 administrative fee per participant per class. Within the week prior to the scheduled start of a class, refund/credits/gift cards will not be given except for verified medical/hardship cases. Should I receive a credit on my account, I understand and agree that I have up to one year to use the credit and if it is not used within one year, the credit will be donated on my behalf to the PRCR Scholarship Fund. Signature: ___________________________________________ Date: ______________________________ 1 Nonresident, pay fee indicated in program description. 2 I would like to donate $1 or more to the scholarship fund. See registration information for more details. (Information provided may be subject to the NC Public Records Law.)

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