REGISTRATION FORM

PLEASE PRINT, FILL OUT COMPLETELY, SIGN AND MAIL OR FAX IT TO: Fredericksburg Parks, Recreation & Events, 408 Canal Street, Fredericksburg, VA 22401 Fax: (540) 372-3475

HOUSEHOLD INFORMATION:

REGISTRATION INFORMATION:

I need a modification because of disability (circle one): YES NO Allergies? YES NO ____________________________

If yes to either above, please explain: __________________________________________________________________________

PAYMENT INFORMATION:

Please check one of the following: Check (make payable to “City of Fredericksburg”) Cash (walk-in only)

Credit Card (Visa, M/C, Discover, Amex)

Credit Card Number: ___________________________________________________________________________________________________

Exp: __________ CVV: __________ Signature: _____________________________________________________________________________

Liability Release:

I understand the nature and scope of the activity listed above. I understand that there are risks and dangers associated with the activity. I understand that it is not the function of the City of Fredericksburg, its employees, agents, operators, or instructors to guarantee the safety of participants with respect to this activity. I also understand that each participant has the responsibility to exercise with due care in the performance of the activity for the safety of him/herself and the other participants.

In consideration of my/the participant’s being permitted to enroll in this activity, I hereby release, indemnify and hold harmless the City of Fredericksburg, its employees, agents, operators, and instructors from any and all claims, demands, costs, charges, and expenses for harm, injury, damage or loss which may be sustained by me/the participant as a result of or relating to participation in this activity.

Also, by signing below, I give Fredericksburg Parks, Recreation and Events permission to use photographs and videos of me and my children for publicity in order to increase community awareness of FPRE programs and in all publications and other media without limitation.

Signature of Parent/Guardian/Participant: ________________________________________________________ Date___________

Sign me up for Fred Parks and Rec’s monthly e-newsletter! r email

Send me the next catalog of activities (like this one): r mail r email digital version