|
 Mail
In or Drop Off
Registration Form to:
Savage Parks & Recreation
Department
13770 Dakota Avenue - Savage MN
55378
Ph: (952) 224-3420 Fax: (952)
224-3430
PLEASE COMPLETE ONE
(1) FORM PER PARTICIPANT
Mail
check for full amount with form
Participant
Name:________________________________________ Date of Birth:
________________Age:__________
Parent/Guardian Name:__________________________________________ Home
Phone:_______________________
Address:_________________________________________________________
Cell Phone:_________________________
City/State/Zip:____________________________________________________
Work Phone:_______________________
Email address
(optional):_________________________________________________ Gender:
___Male or ___Female
Please indicate the Activity name and Activity # that you are
registering for below.
Activity Name: ____________________________________
Activity Name: ___________________________________
Activity #: _____________________ Fee: __________
Activity #: ____________________ Fee: ________
Activity Name: ____________________________________
Activity Name: ___________________________________
Activity #: _____________________ Fee: __________
Activity #: _____________________ Fee: _________
Activity Name: _____________________________________
Activity Name: ___________________________________
Activity #: _____________________ Fee: __________
Activity #: ______________________ Fee: ________
I hereby release, absolve
and hold harmless the City of Savage, its officers, employees and
agents from any damage resulting from any injury incurred by me or
my child while participating in the above mentioned programs. I/We
understand that the City of Savage assumes no responsibility for
injury before, during or after programs. All information contained
in or connected with this registration form will be considered
personal and confidential and will be used only in conjunction with
the registration process for programs sponsored by the City of
Savage.
Date Privacy Act
In accordance with the Minnesota Government Data Practices Act, the
Recreation Department hereby informs you that the personal
information we are requesting of you and/or your child or guardian
on our registration form is now considered private. Private data is
available to you and to City staff who need to have this information
to perform their duties, but not to the public. While you may choose
to withhold this data, the consequences could be that the City's
Recreation staff may not be able to complete your registration
and/or you may not receive updated program information, such as
schedule changes.
Signature:
__________________________________________________ Date:
______________________
Office use only
Total Due: $_____________ Check #: ____________ Cash: _____ Date:
___________ Rec. by: _________ |