Recreation brochure - Mequon-Thiensville School District

PAGE 79
MEQUON-THIENSVILLE RECREATION DEPARTMENT REGISTRATION FORM - SUMMER 2014
First/Last Name (person completing the form)
Address
City State Zip Home Phone
Work/Day Phone Cell Phone
Email Address Please note any special needs or comments:
PARTICIPANT:
First Name Last Name M/F
Age
(only if 18 or under)
Date of Birth
(only if 18 or under)
Grade
In 14-15 Program Title (Level) Course #
Program
Fees
All participants are requested to sign the following release. Parent or Guardians must sign for minors.
Total Fees
I/We the undersigned, do hereby agree to allow the above named to participate in the activity indicated.
I am/We are aware of and understand that there may be potential risks inherent with participating in any
recreational activities and that the Mequon-Thiensville School District and the M-T Recreation
Department does not provide accident insurance. I/We assume all risks and hazards incidental to such
participation including transportation to and from the activities and do hereby waive, release, absolve,
indemnify and agree to hold harmless the M-T Recreation Department employees, staff, and other
persons for any and all claims, injuries, liabilities, damage or right of action directly or indirectly arising
out of use of M-T Recreation Department activities. In the event of a medical emergency, I authorize
the department staff to obtain medical treatment for the above named. I and my child hereby
acknowledge having received education found on the Rec Dept website or in the Rec Dept
office about the signs, symptoms, and risks of sport related concussions. I and my child
acknowledge our responsibility to report to our coaches, parent(s)/guardian(s) any signs or
symptoms of a concussion.
SIGNATURE:__ _______________________________ DATE:_________________________
MAIL TO: M-T Recreation Department, 11040 N. Range Line Rd., Mequon, WI
53092 OR FAX: (262) 238-7550. Please double check that the form is
completed in its entirety. For questions/assistance PHONE: (262) 238-7535.
Date Processed: ________ / ________ / ________
______ Check (payable to M-T Recreation Department
______ Cash
______ Credit Card ______ MasterCard ______ Visa
Card #: _____________________________________
Expiration Date: ______ / ______
Card Verification #: ___ ___ ___
(See back of card.)
Card Holder Name: ____________________________
Signature:____________________________________
Please refer to the M-T Recreation Department brochure or www.mtsd.k12.wi.us
for specific registration refund policies.