Activity Registration Form

San Ramon Resident
Non-Resident
GO Card Member
GO Card Encore
San Ramon Parks and Community Services Department
Activity Registration Form
Please Submit to: San Ramon Community Center at Central Park - 12501 Alcosta Blvd San Ramon, CA 94583 Fax: 925-830-5162 Tel: 925-973-3200
PLEASE PRINT & COMPLETE EACH LINE
Main Contact Name-Parent/Legal Adult Name
Last Name: _______________________ First Name: ________________ Primary Phone: (____)______________
Complete this section if you have NOT enrolled in an activity or changed your address since Winter/Spring 2015.
Street Address:___________________________________________________ City:_____________________________
Zip:_________ Business Phone:(____)____________ Emerg. Phone: (____)____________ Cell Phone: (_____)_________
E-mail:[email protected]_______________________
Office Use Only: MC Barcode: __ __ __ __ __ __
Registration form limited to family members only!
MC Name: First ___________________________
Last ___________________________
To assure our programs benefit all who attend, please check if applicable:
q Please check here if the participant has Special Needs requiring special accommodations
q Please check here if the participant has a Life Threatening Medical Condition in order for staff to provide appropriate accommodations.
Activity Registration: This registration is for (circle one): Winter
PARTICIPANT-first and last
(Use one line for each person or course)
CLASS TITLE
Act#
Spring
Summer
Alternate
Act#
Fall
Birthdate
(mm/dd/yy)
Current
Grade
Male/
Female
Course
Fee $
1.
2.
3.
Become A Go Card Member: ❑ San Ramon Residents $69 ❑ Non-Residents $99 ❑ Non-Residents Summer Only $49
Refunds: Patron requested refunds or transfer requests will be approved only if initiated no
later than 7 business days prior to the first day of class. All Refunds/Transfers will be charged
a processing fee of $5 for classes less than $72, each class over $72 will be charged 7% of fee.
Total Fees
I have read and understand the refund policy and the following Waiver of Liability: This release is intended to discharge in advance the City of San Ramon, including all of its respective
agents, officials, volunteers, sponsors and employees, from and against any and all liability arising out of or connected in any way with me or my child/legal guardian’s participation
in the above activities, even though the liability may arise out of active or passive negligence or carelessness on the part of the persons or entities mentioned above. I understand the
inherent risks involved in participating in recreational activities including but not limited to terrain, facilities, temperature, weather, condition of participant, equipment, and lack of
hydration. Furthermore, I hereby agree that I, my heirs and assignees will not make claim against, sue, attach the property of, or prosecute the City of San Ramon and any sponsor,
or any affiliate organization for injury or damage resulting from active or passive negligence, carelessness or other acts, howsoever caused by any employee, agent or contractor of
the City of San Ramon or its affiliates, as a result of my participation in the above activities. In the event that the above named individual is a minor, I certify that I am the legal parent
or guardian of the above participant, that he/she is in good physical condition and I give my permission for him/her to participate in the above activities. I hereby acknowledge that
the above named minor has voluntarily applied to participate in the above activities. I agree to accept and abide by all rules and regulations of the event/program and the city of San
Ramon. The City of San Ramon and its staff are authorized to use their discretion to secure the necessary emergency services for the participant at my expense. This includes, but is not
limited to emergency treatment, paramedic services and ambulance services. I hereby grant permission to the City to release my email address to contract instructors, coaches, or other
City program providers for City business purposes. I hereby grant permission to the City to take me or my child/legal guardian’s photo while participating in activities or programs to use
for publicity. A signature is required by each adult participant registering on this form. One parent/legal guardian may sign for all minors. I understand that my signature is a legal and
binding signature and will be considered original if received by electronic means.
Total Amount
Signature ________________________________________________
q Self
q Parent
q Guardian
Charge to my:
q MasterCard
q VISA
Date _______________
Enclosed
Online Registration
Register or Check Course
Availability Online:
www.SanRamon.ca.gov
To Purchase Tickets:
www.sanramonperformingarts.com
Do Not Use This Form
See Registration Information
for details
q American Express
Print name as it appears on card ___________________________________________________________________________________
Expiration Date ___________________
Authorized Signature _________________________________________________________
Card No. ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
NOTE: Entire section must be completed for registration to be processed.
Amount $_____________________________