City of Laguna Niguel Contact Information: Parks and Recreation Department Crown Valley Park REGISTRATION FORM 29751 Crown Valley Parkway Laguna Niguel, CA 92677 ONE FORM PER PERSON REQUIRED (949) 425-5100 [email protected] PARTICIPANT’S NAME: _____________________________________________________ SEX ____ D.O.B_____/_____/_____ GRADE ________ PARENT/GUARDIAN NAME (if participant is a minor): __________________________________________________________________________ ADDRESS _______________________________________________________________ CITY _______________________ ZIP ______________ HOME PHONE ( _____ ) ______ - __________ WORK PHONE ( _____ ) ______ - _________ CELL PHONE ( _____ ) ______ - ___________ EMAIL ADDRESS __________________________________________________________@ ___________________________________________ EMERGENCY CONTACT (other than parent) _______________________________________________ PHONE ( _____ ) ______ - ___________ MEDICAL INFORMATION ________________________________________________________________________________________________ If you need special assistance, please contact the Parks and Recreation Department at least one week prior to the start of activity. ACTIVITY # NAME OF ACTIVITY DAY/TIME CHECK # FEE I voluntarily agree to have myself or my child participate and I realize that every precaution is taken to eliminate any injury or hazards to myself or my child, and that a competent supervisor is present; however, in the event of any injury to myself or my child, I hereby waive, release and hold harmless from any liability for damages or claims for damages for personal injury, including accidental death, as well as from claims for personal property damage which may arise in connection with the program, against the City of Laguna Niguel and all it’s o昀케cers, agents and employees. I give consent to any X-Ray examination, anesthetic, medical or surgical diagnosis tendered under the general or special supervisor of any member of the medical sta昀昀 and emergency room sta昀昀 licensed under the Medicine Practice Act or a dentist licensed under the Dental Practice Act or the sta昀昀 of any acute General hospital holding a license to operate from the California Department of Public Health. It is understood that this authorization is given in advance of diagnosis, treatments, or hospital care being required but is given to provide the aforementioned medical/dental personnel authority to render care as they deem advisable. It is understood that e昀昀orts shall be made to contact the undersigned prior to rendering treatment, but that treatment will not be withheld if the undersigned cannot be reached. I permit the use of activity/event photography and/or video of my child or myself for LN Parks & Recreation media promotion. I HAVE READ AND UNDERSTAND THIS RELEASE FROM LIABILITY AND THE CANCELATION/REFUND POLICY. ________________________________________________________________________________ Date _________/_________/_________ (Signature) Parent or Guardian must sign for those under 18 years of age PAYMENT INFORMATION: NAME ON CARD_____________________________________________________________________________________________________ CREDIT CARD NUMBER __________________________________________________________ EXP DATE _________/_________/_________ 3-DIGIT CVC CODE ______________ 32