Open to Adults & Seniors - Mequon-Thiensville School District
Open to Adults & Seniors - Mequon-Thiensville School District
Open to Adults & Seniors - Mequon-Thiensville School District
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PAGE 58<br />
MEQUON-THIENSVILLE RECREATION DEPARTMENT REGISTRATION FORM — FALL 2012<br />
First/Last Name (person completing the form)<br />
Address<br />
City State Zip Home Phone<br />
Work/Day Phone Cell Phone<br />
Email Address Please note any special needs or comments:<br />
Program Fees<br />
Course #<br />
Program Title (Level)<br />
Grade<br />
In 12-13<br />
Date of Birth<br />
(only if 18 or under)<br />
Age<br />
(only if 18 or under)<br />
PARTICIPANT:<br />
First Name Last Name M/F<br />
Total Fees<br />
All participants are requested <strong>to</strong> sign the following release. Parent or Guardians must sign for minors.<br />
Date Processed: ________ / ________ / ________<br />
______ Check (payable <strong>to</strong> M-T Recreation Department<br />
______ Cash<br />
______ Credit Card ______ MasterCard ______ Visa<br />
Card #: _____________________________________<br />
Expiration Date: ______ / ______<br />
Card Verification #: ___ ___ ___<br />
(See back of card.)<br />
I/We the undersigned, do hereby agree <strong>to</strong> allow the above named <strong>to</strong> participate in the activity indicated.<br />
I am/We are aware of and understand that there may be potential risks inherent with participating in any<br />
recreational activities and that the <strong>Mequon</strong>-<strong>Thiensville</strong> <strong>School</strong> <strong>District</strong> and the M-T Recreation<br />
Department does not provide accident insurance. I/We assume all risks and hazards incidental <strong>to</strong> such<br />
participation including transportation <strong>to</strong> and from the activities and do hereby waive, release, absolve,<br />
indemnify and agree <strong>to</strong> hold harmless the M-T Recreation Department employees, staff, and other<br />
persons for any and all claims, injuries, liabilities, damage or right of action directly or indirectly arising<br />
out of use of M-T Recreation Department activities. In the event of a medical emergency, I authorize<br />
the department staff <strong>to</strong> obtain medical treatment for the above named. I and my child hereby<br />
acknowledge having received education found on the Rec Dept website or in the Rec Dept<br />
office about the signs, symp<strong>to</strong>ms, and risks of sport related concussions. I and my child<br />
acknowledge our responsibility <strong>to</strong> report <strong>to</strong> our coaches, parent(s)/guardian(s) any signs or<br />
symp<strong>to</strong>ms of a concussion.<br />
SIGNATURE:__ _______________________________ DATE:_________________________<br />
Card Holder Name: ____________________________<br />
Signature:____________________________________<br />
MAIL TO: M-T Recreation Department, 11040 N. Range Line Rd., <strong>Mequon</strong>, WI 53092<br />
OR FAX: (262) 238-7550. Please double check that the form is completed in its<br />
entirety. For questions/assistance PHONE: (262) 238-7535.<br />
Please refer <strong>to</strong> the M-T Recreation Deparent brochure or www.mtsd.k12.wi.us for specific registration refund policies.