Issue link: http://townofcary.uberflip.com/i/217218
Mailing Address_______________________________________________________________________________ City_____________________________________ ST_____________________ ZIP__________________________ Home Phone_________________________________ *E-mail Address________________________________ (Subject to Public Records Law) How do you prefer to receive your registration receipt? q Email Valid email address required. q Printed/Mailed *By providing my e-mail address I agree to receive e-mail communication from Town of Cary. Work or Cell Phone___________________________ Date of Birth__________________________(required) Local Emergency Contact Name:______________________________________________________(required) Local Emergency Relationship:_________________________________________________________(required) Local Emergency Contact Phone Number:______________________________________________(required) Are you a Cary Resident? q Yes q No Class CodeClass/Workshop Title Gender: Day q Female q Male Date(s) Time Fee* _______________ ______________________________ ___________ _________ _________ _______________ _______________ ______________________________ ___________ _________ _________ _______________ Additional space for more classes on the back _________ _______________ _______________ ______________________________ ___________ _________ >>> The Town of Cary provides the opportunity for Cary residents to apply for scholarships and/or reduction of fees for Parks, Recreation & Cultural Resources' programs. If you are interested in donating $1 or more to the scholarship fund, please indicate it in the total on your registration form and include it in your check. Thank you ! MAKE CHECKS PAYABLE TO "Town of Cary" Scholarship Donation: $_________________ I would like to donate $1 or more to the scholarship fund. Total from other side: $_________________ See registration information for more details. Total from this side: $_________________ *Nonresident, pay fee indicated in program description. Total Amount Due: $_________________ 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 date of the program/class. Each request will be assessed in compliance with the ADA. q YES 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 portion of the program is unable to be completed due to inclement weather or other unforeseen circumstances, I will receive a prorated credit on my account for the uncompleted portion of the program. Further, I understand and agree that I have up to one year to use the credit and if it is not used within the one year, the credit will be donated on my behalf to the PRCR Scholarship Fund. Signature:___________________________________ Date:________________ WAIVER MUST BE SIGNED Registration Dates: December 2 (Cary Resident – EZ Reg Web, EZ Reg Mail-In, EZ Reg Phone) December 16 (Non Resident – Any EZ Reg Method) Mark Your Calendars! Mailing Address: Cary Senior Center • P.O. Box 8005 • Cary, NC 27512-8005 Registration Form Participant's Last Name__________________________________ First Name_____________________________________