Issue link: http://townofcary.uberflip.com/i/346682
Town of Cary Parks, Recreation and Cultural Resources Department Program Registration Form Main Contact Last Name ______________________________________________ First Name ___________________________________________________ q Male q Female 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 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 ______________ _____________________________ _______________________________ _________ __________ ________ ______________ _____________________________ _______________________________ _________ __________ ________ 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 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: _____________________________ 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.)