SUN Community Schools - Winter 2015

Winter 2015 Activities in North & Northeast Portland

SUN Community School Activities

Commissioner Amanda Fritz Director Mike AbbatĂŠ

REGISTRATION BEGINS NOVEMBER 24, 2014

Go to PortlandParks.org, click on the Register Now tab.

Portland Parks & Recreation - Winter 2015 SUN COMMUNITY SCHOOLS - NORTH ZONE

Schools Uniting Neighborhoods At SUN Community Schools, the collective efforts of youth, parents, businesses, faith communities, libraries & community organizations create a network of supports that ensure academic success, family self-sufficiency & economic prosperity. SUN Community Schools are open to all ages, preschool to seniors, with a focus on students in the immediate school community.

SUN CS are a collaboration of Multnomah

County, the City of Portland, nonprofits & local school districts.

Beaumont SUN Community School 4043 NE Fremont St 97212

Contact Us Site Manager: Sue Coffman Phone: 503-916-5615 Email: Sue.Coffman@portlandoregon.gov

www.Facebook.com/BeaumontSUN Intergenerational

Education Writing - Let Your Imagination Fly ages: 8 & up Fly to the moon! Sail to the stars! Send thoughts aloft on a paper airplane. Imagine yourself an astronaut or bird & write stories or poetry about your travels!

Increase communication & self- expression skills while improving basic writing abilities.

1019705 Th 6:30pm-7:30pm

Rm 20 1/8-3/12 $45 2 North & Northeast Portland 503-823-PLAY

Fitness & Health Belly Dance ages: 9 & up Shimmy & swirl! Get those hips, legs & stomach muscles moving increasing strength, flexibility & endurance! A total aerobic workout inspired by exotic music from the Far East, designed to get you moving, grooving & in good shape!

1020293 Tu 7pm-8:30pm

Cafe 1/6-3/10 $50

Sports - Badminton Badminton Drop-In age: 8 & up Come and experience the game the way it was meant to be played. Badminton is an exciting, fast paced, coed, Olympic sport that gives you a terrific aerobic workout without beating you up. You can participate in open play or take a lesson from a USAB Certified Level 1 Coach. No gym on 1/19 & 2/16.

M,W 6pm-9pm

Big Gym 1/5-3/16 $3 (Drop-In)

Portland Parks & Recreation

Sports - Fencing Fencing - Introduction To Foil ages: 8 & up Experience the art of swordsmanship with a dynamic sport teaching safety, self-discipline, coordination, agility, stamina, speed & grace. Tactics, techniques, footwork & blade work build strength, balance & quick reactions & a mastery of strategy & a life-long recreational activity.

1020435 W 6pm-7pm

Cafe 1/7-2/25 $36 Tae Kwon Do - Drop In age: 8 & up Join over 40 million people who practice this Korean martial art. Increase agility & strength while improving coordination using kicks, punches & blocks. Parents, children & families are welcome.

Tu 7pm-8:30pm

Sm Gym 1/6-3/16 $3 (Drop-In)

Schools Uniting Neighborhoods

Preschool (2yrs - 6yrs)

Performing Arts - Ballet PreBallet – Where Dreams Begin ages: 3-6 Earliest preparation of time honored training in classical ballet. Agility, grace, coordination, movement & rhythm improves strength while providing the nurturing atmosphere to learn the discipline required.

No class on 1/19 & 2/16.

1019235 M 4pm-4:30pm

Cafe 1/5-3/16 $31.50

Youth (School Age/ 6yrs - 17yrs)

Sports - Martial Arts Tae Kwon Do - For Everybody ages: 7-15 Join over 40 million people who practice this Korean martial art. Increase agility & strength while improving coordination using kicks, punches & blocks.

1020304 Tu 6pm-7pm

Cafe 1/6-3/10 $50

SUN Community Schools,

SUN Community Schools bring the community together to support educational success.

a great place to work and play!

SUN Community

SUN Community Schools are a collaboration of Multnomah County, the City of Portland, nonprofits, and local school districts.

Register On-Line at www.PortlandParks.org

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Portland Parks & Recreation - Winter 2015

Education

Teen (11yrs - 17yrs)

At Home Alone ages: 8-11 This Kidproof course ensures important skills are learned through interactive lessons & role play that help make both you & your child more confident when they are at home alone, including their rights & responsibilities, responding safely to phone calls & unexpected visitors, keeping constructively occupied & responding to emergencies. This class is presented

by Community Upgrade, an authorized provider of Kidsproof Safety International Programs. Class starts at 5:30pm sharp, please be on time. No refunds/ cancellations after 2/13.

1019737 W 5:30pm-8pm

Rm 20 2/18 $35

Performing Arts Dance - Tap & Jazz Combo ages: 6-10 Sizzle & swing your way to versatility! Tapping builds speed & stamina & jazz limbers up the whole body. Basic shuffles, toe taps & waltz clogs challenge your physical coordination & provide the chance to be cool, be alive & jive.

1019710 Th 5pm-6pm

Cafe 1/8-2/5 $25 1019711 Th 5pm-6pm

Cafe 2/12-3/12 $25

Performing Arts - Ballet Ballet - First Steps ages: 6-10 Inspired by the Sugar Plum Fairy & Nutcracker Prince. The time honored training of classical ballet stretches the mind & body while teaching agility, grace, coordination & strength providing a basis for all types of dance, sport & movement. No class on 1/19 & 2/16.

1019706 M 5pm-6pm

Cafe 1/5-3/16 $51.75

TriMet

TriMet provides bus, light rail and commuter rail transit services in the Portland, Oregon, metro area. To find schedules for a specific bus line visit www.trimet.org

SUN CS SITES Beaumont Faubion Roseway Heights Sitton

BUS LINES #24 #75 #75 #70 #17 #12 #33 #72 #16 #44 #75

4 North & Northeast Portland 503-823-PLAY

Education Babysitter Training ages: 11-16 This KidProof course provides interactive discussion, activities & hands-on practice to increase your confidence & give you the skills you need to be the best sitter possible. Topics include how to acquire a babysitting job, caring for kids of all ages, dealing with difficult situations, developing fun activities, making safe choices & basic first aid. This class is presented

by Community Upgrade, an authorized provider of Kidsproof Safety International Programs. Class starts at 9am sharp, please be on time. No refunds/ cancellations after 1/28. Participants should bring a sack lunch and water bottle.

1019728 F 9am-4pm

Rm 20 1/30 $65

High School/Adult (12 yrs & up)

Fitness & Health Yoga: Conditioning ages: 11 & up Relaxation is one of the most important & beneficial skills to learn. Benefit mind & body while expanding strength, stamina & flexibility. An excellent way to learn to meet the changing demands of daily life while increasing a sense of well being. No class on 1/19 & 2/16.

1020292 M 7pm-8pm

Cafe 1/5-3/16 $50.50 Zumba: Fitness ages: 11 & up Routines combine fast & slow rhythms to achieve a balance of cardio & muscle-toning benefits. A dynamic, exciting & effective workout! Move fast & have fun!

1020294 Th 6:30pm-7:30pm

Cafe 1/8-3/12 $72

Need a scholarship?

To apply, contact your preferred SUN CS and inquire today!

Portland Parks & Recreation

Faubion SUN Community School 3039 NE Rosa Parks Way 97211 Contact Us

Site Manager: Autumn Montegna Phone: 503-916-5694 Email: Autumn.Montegna@portlandoregon.gov Adult/Child (Adult must attend)

Sports - Soccer Soccer - You & Me ages: 2-4 Don’t watch from the sidelines! An introduction to the ‘World’s Most Popular Game’! Interact with your child as you both learn the basics - pass, trap, dribble & shoot. Gain confidence, bond & exercise! It’s a goal!

1020070 F 5pm-5:30pm

Gym 1/9-3/13 $45

High School/Adult (12 yrs & up)

Fitness & Health Fitness - Yoga: For Everyone ages: 18 & up Relax your mind & body while improving strength, stamina & flexibility. Relieve the streeses of daily life with these revitalizing techniques. This centuries old practice of exercise increases your focus & sense of well-being.

1020068 W 6:30pm-7:30pm

Cafeteria 1/7-2/4 $40 1020069 W 6:30pm-7:30pm

Cafeteria 2/11-3/11 $40

Golden Opportunities For senior citizens, retirees & grandparents to get invloved in SUN Community Schools

Preschool (2yrs - 6yrs)

Sports - Sports Mix Sports Mix - Gym Jamboree ages: 3-6 Does your child love to run, jump, twirl & play?

Build strong & healthy bodies, work on motor skills, coordination, balance, flexibility & social development as they interact. All sorts of activities, from soccer to kickball - maybe even a crazy obstacle course while burning off extra energy! Let’s go! Adult must attend.

1020071 F 5:30pm-6pm

Gym 1/9-3/13 $39.75

Youth (School Age/ 6yrs - 17yrs)

Sports - Basketball

• Advocate for educational excellence • Share your expertise SUN Community

Basketball - In the Zone ages: 6-9 Challenge yourself! Emphasis on ball handling, shooting techniques & footwork. Increase endurance, flexibility & strength while encouraging teamwork & sportsmanship.

1020066 W 5:30pm-6:15pm

Gym 1/7-2/4 $33 1020067 W 5:30pm-6:15pm

Gym 2/11-3/11 $33

• Advise on curriculum

Call 503-823-7112 to find out how you can help build community!

Register On-Line at www.PortlandParks.org

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Portland Parks & Recreation - Winter 2015

Roseway Heights SUN Community School

Sitton SUN Community School

7334 NE Siskiyou St 97213

9930 N Smith St 97203

Contact Us Site Manager: Shelby Coshow Phone: 503-916-5865 Email: Shelby.Coshow@portlandoregon.gov Preschool (2yrs - 6yrs)

Contact Us Site Manager: Peg Zander Phone: 503-916-5654 Email: Peg.Zander@portlandoregon.gov Intergenerational

Sports - Skateboarding

Arts & Crafts

Skateboarding - Junior Skate Club ages: 5-6 Do you have a little one that wants to ride? Start off right with beginner basics to build confidense and skill.

Let’s Roll! Loaner boards & helmets available.

1019522 W 4:30pm-5:30pm

Small Gym 1/7-2/4 $20 1019523 W 4:30pm-5:30pm

Small Gym 2/11-3/11 $20

Crafts - Knitting: The New Age ages: 12 & up It’s not just your grandmother’s craft! New yarns & techniques allow you to produce a variety of simple projects. Anyone can do it! Relax & enjoy the results of your creative efforts, both beautiful & functional.

Bring one light colored skein, worsted weight yarn & size 6 needles. No class on 1/19 & 2/16.

1020044 M 6pm-7pm

Cafeteria 1/5-2/2 $10 1020045 M 6pm-7pm

Cafeteria 2/9-3/16 $12.50

High School/Adult (12 yrs & up)

Fitness & Health Fitness - Tone Zone ages: 18 & up A fun combination of cardio, core conditioning, resistance training, strength building, dance moves, stretching & more for improved posture, balance, strength, flexibility & stamina all day & beyond. No class on 1/19 & 2/16.

1020437 M, W 6pm-7pm

Small Gym 1/5-2/4 $54.50 1020438 M, W 6pm-7pm

Small Gym 2/9-3/16 $54.50

Sports - Basketball

Youth (School Age/ 6yrs - 17yrs)

Arts & Crafts Crafts - Work With Your Hands ages: 6-12 There’s nothing more exciting than embracing personal creativity. Through a variety of materials & techniques, gain knowledge & skills that can be reused to make special ‘treasures’ at home. A handmade original! No class on 1/19 & 2/16.

1020040 M 5pm-6pm

Cafeteria 1/5-2/2 $10 1020042 M 5pm-6pm

Cafeteria 2/9-3/16 $12.50

Basketball - Retro Rebounders age: 30 & up Bad knees? Sore back? Jumping abilities that aren’t what they used to be? Here’s an opportunity to get a workout & increase strength, flexibility, & endurance at a slower pace. Drop-in only, do not register. Contact RWH SCS at 503.916.5865 for confirmation – subject to cancellation due to school events.

Tu 6:30pm-8:30pm

Lrg Gym 1/6-3/10 $2 (drop-in) Disability Access: All SUN CS facilties meet accessibility standards as required by state and federal law.

6 North & Northeast Portland 503-823-PLAY

Portland Parks & Recreation

Within the Americans with Disability Act (ADA) of 1990, Portland Parks & Recreation (PP&R) provides accommodations to individuals with disabilities/special needs, so that they may receive an equal opportunity to participate in programs offered citywide.

1. Choose the activity you would like to participate in, and then the PP&R site where the activity is being offered.

2. Register for the activity. You can do this in person at a PP&R site, or on-line at www.

PortlandParks.org. When registering, let the person know that you will need accommodations in order to participate in the activity (online, check the box.)

3. Once registered, please contact Inclusion Services at 503-823-4328. If this is your first accommodation through Inclusion Services you will need to do a phone intake with a staff member. At the end of the phone intake, it will be determined whether an assistant will be needed on the first day of the activity to provide on-site support. Future assistance will be provided based on need. The inclusion staff will work with the instructor on how to support you and your individual needs.

If you have questions about Inclusion Services, please call 503-823-4328 V/TTY. A minimum of 10 business days (Monday-Friday) advance notice is required. The Inclusion Services staff will do their best to accommodate each participant.

SUN Community

A general program may be adapted using auxiliary aids and services, but the basic structure of the program remains the same. Accommodations are made as needed, and can be flexible and creative.

Participants need to register for activities that are intended for their birth age. Personal care is provided for activities in the pre-school and youth category, up through age 12.

2015 race dates coming soon!

Keep up with us on Facebook and Twitter.

Facebook.com/5dollar5k Twitter.com/5dollar5k

Register On-Line at www.PortlandParks.org

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Portland Parks & Recreation - Winter 2015

Charles Jordan Community Center 8 North & Northeast Portland 503-823-PLAY

Portland Parks & Recreation

503-762-3463

Register On-Line at www.PortlandParks.org

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SCHOLARSHIP APPLICATION for Classes & Programs THIS FORM IS FOR CLASSES & PROGRAMS ONLY. FOR INFORMATION ON MEMBERSHIP SCHOLARSHIPS CONTACT YOUR LOCAL COMMUNITY CENTER. FACILITY NAME:____________________________________ PROGRAM/ACTIVITY:______________________________ Portland Parks & Recreation recognizes that some residents of the City of Portland require financial assistance to attend certain recreational activities. A limited number of scholarships are available for those who qualify. The information requested below is confidential and necessary to help determine the degree of need for each applicant. ALL information must be filled in or the application will be returned unaccepted. If you are applying for multiple scholarships, a separate application is required for each participant and for each activity. Please allow a minimum of 2 working days to process your scholarship. Call or come in to the recreational facility to confirm approval of your scholarship.

Proof of income is required with ALL scholarship applications. Please see reverse for more information and valid forms of income verification.

Participant’s Name: _______________________________________________________________ Age: ___________________ Address: ________________________________________________________________________________________________ City________________________________________ State:_______________________ Zip Code: ______________________ Daytime Phone:________________________________________ Evening Phone: ____________________________________ This scholarship will be used for: Activity: ___________________________________ Barcode:________________________ Knowing that the normal fee for this program is $_______________ what do you think you can pay? $_______________ Our program does not allow us to cover the program fee completely, so please enter an amount that is possible for you to pay.

State the financial need which makes it impossible for you to pay entire fee: __________________________________________ _______________________________________________________________________________________________________ FOR YOUTH REGISTRATIONS ONLY: Father’s Name: ____________________________________________ Employer:____________________________________ Mother’s Name: ___________________________________________ Employer:_____________________________________

____________________________________________________________________

Participant / Parent / Guardian Signature FOR OFFICE USE ONLY:

_____________________ Date

Notes:

Date Received: ____________________ Date Approved: ____________________ Regular Program Fee: $ ________________ Term: ___________________________ Dates Phoned: _____________________ Less Scholarship Amt: $ ________________ Program Manager Signature: _________________________________________ Total Participant Fee: $ ___________________ Dates Phoned: ____________________________________________________________________________________________ Sustaining a healthy park and recreation system to make Portland a great place to live, work and play. www.PortlandParks.org • Commissioner Nick Fish • Director Mike Abbaté

VERIFICATION OF INCOME ELIGIBILITY When applying for a scholarship, Portland Parks & Recreation requires a copy of your latest 1040 Income Tax Form or other accepted form to verify your income (see below). This information must be update with each subsequent scholarship request. Portland Parks & Recreation values your privacy and will make every effort to ensure information provided remains confidential.

Number of children living at home: ___________Number of adults in household: __________ TOTAL YEARLY FAMILY INCOME (include child support if applicable):

o 0 to $19,239 o $19,240 to $25,899 o $25,900 to $32,559

o $32,560 to $39,219 o $39,220 to $45,879 o $45,880 to $52,539

o $52,540 to $59,199 o $59,200 to $65,859 o Over $65,859

ACCEPTABLE forms of income verification (please check form used): _____ _____ _____ _____ _____

Most recent 1040 income tax return Proof of current Social Security benefits (SSA Benefit Statement or SSA-1099) Proof of disability pay (SSI) Proof of current OHP (Oregon Health Plan – striped medical paper with client info on it) Oregon Trail (food stamps) award letter

UNACCEPTABLE forms of income verification: • Bank Statements • Paycheck stubs • Individual W-2’s • Plastic Oregon Trail Card • WIC To the best of my knowledge, the information provided on the Verification of Income Eligibility form is accurate.

I understand that misrepresenting could result in an inability to receive Portland Parks & recreation scholarships in the future.

Signature of Participant (18 & older or Parent/Guardian

Date

FOR OFFICE USE ONLY After review by staff, proof of eligibility was:

q Return to customer q Shred

Date: _______________ Staff Name: ______________ Date: _______________ Staff Name: ______________ Register On-Line at www.PortlandParks.org 11

Portland Parks & Recreation - Winter 2015 REGISTRATION

NOTICE OF NON-DISCRIMINATION

Receipt of full payment is required for registration, unless otherwise arranged. Please call if you receive a returned check or declined bank card notice, either of which void registration.

PP&R programs and services reflect the cultural diversity of our community. We do not discriminate on the basis of religion, race, color, gender, national origin, sexual orientation, age or ability.

RESIDENT / NON-RESIDENT

SPECIAL NEEDS

A resident is:

Within the American with Disability Act (ADA), a person with a disability or special need who desires assistance with registration and/or participation in general PP&R programs can contact Inclusion Services at please call 503-823-4333 or 711 (TRS). If you request assistance through Inclusion Services, a minimum of 10 business days (Monday-Friday) advance notice is required.

• anyone who occupies a permanent residence inside the city limits of Portland. At the discretion of a Community Center Director, proof of home address may be required.

Acceptable address verification may include a 1) drivers license, 2) Oregon ID card, 3) property tax statement, 4) utility bill or lease agreement with current home address.

Registration Information

• any child living within the school boundaries of the Reynolds and Centennial School Districts who is attending a SUN Community School. Through a partnership between the City and County, a child attending a SUN Community School is eligible to register for programs at any SUN Community School location without paying a non-resident surcharge.

Anyone else is considered a non-resident (NR) and will be assessed a 40% surcharge. NR surcharges do not apply to drop-in activities. Non-residents who wish to register for PP&R activities may choose one of these options: • Pay the additional 40% NR fee.

• Purchase a NR fee discount pass as either an individual or family for a period of three, six or nine months from the date of purchase. The NR discount pass takes 25% off the NR fee for the activity. Inquire about this option at time of registration. These passes are not refundable.

Non-resident Pass Prices 3-month pass: Individual $25 Family $50 6-month pass: Individual $45 Family $90 9-month pass: Individual $65 Family $130 A family denotes a couple (married or domestic) or a single parent and their legal dependents living in the same residence.

CLASS ENROLLMENT Our classes must meet minimum and maximum enrollment standards. Classes may fill quickly or be canceled due to low enrollment.

WITHDRAWAL & REFUNDS Please notify us at least five (5) business days (MondayFriday), unless otherwise specified, before the start of your program so that we can refund or credit your account for the registration fee. Pre-paid materials and admission tickets cannot be refunded. Participants needing to withdraw after the program has begun are offered a prorated credit or refund based upon when the request is made.

SCHOLARSHIPS City of Portland residents, regardless of age, who require financial assistance may apply for partial scholarships.

Contact individual centers for information.

12 North & Northeast Portland 503-823-PLAY

If you need a sign language interpreter or FM loop amplifier, please contact please call 503-823-4333 or 711 (TRS), at least five business days in advance of the activity or class.

Information about programs and services is available online for those needing a voice synthesis; visit our website at www.

PortlandParks.org. For additional ADA information, call 503823-2223.

PHOTO POLICY Portland Parks & Recreation (PP&R) reserves the right, and may give permission to the media, to photograph classes, programs, and participants at any of our facilities and properties or any sponsored activity. Please be aware that these photos are for promotional purposes and may be used in future publications and media communications in any format.

If you do not wish to be photographed, please inform staff and we will make reasonable efforts to honor your request.

If you see staff taking pictures, and you do not wish to be photographed, please let us know.

If you see a photo of yourself or a family member that causes you concern, please notify us. As a courtesy, we will make every reasonable effort to dispose of the image, and will not use it in future publications. However, we will not be able to retrieve, destroy or discontinue existing printed publications in which the photograph may have been included.

CUSTOMER SATISFACTION Your satisfaction is our goal! Portland Parks & Recreation strives for 100% customer satisfaction. If you are not satisfied with a recreation program or service, please let us know.

INFORMATION HOTLINE For information on other PP&R services & programs, call our Information Hotline at 503-823-PLAY (7529), MondayFriday, 8:30am-5pm.

INCLEMENT WEATHER If the City of Portland public school districts (Portland Public, Parkrose, David Douglas, Reynolds, and Centennial) are closed because of weather conditions, PP&R classes and youth basketball in those school districts are cancelled.

However, some sites may be open for drop-in activities. Call the specific PP&R facility for information and opening/ closing times. If inclement weather is forecast on weekends or holidays, call the PP&R facility or program for operating hours and activity cancellations.

Register Now – One of Five Ways ONLINE at PortlandParks.org – Click on the “Register Now!” top tab. Search for classes by age, category, location or keyword – or narrow your search by specific activity or course number.

PHONE – Complete this registration form and call any PP&R site using the phone numbers on the map pages.

You may also phone in your registration to the PP&R Customer Service Hotline at 503-823-2525, MondayFriday, 8:30am-5:15pm. Only Visa, MasterCard or American Express accepted with phone-in registration.

MAIL – Mail your completed registration form to the program center address. Include full payment using your Visa, MasterCard, American Express or check payable to the City of Portland. Mail-in registration is also received at the PP&R Customer Service Center, 1120 SW Fifth Ave, Suite 1302, Portland, OR 97204.

FAX – Complete the registration form and fax it to 503-823-2515 with full payment using your Visa, MasterCard or American Express. Faxes are accepted 24 hours a day, seven days a week, but are processed during regular business hours.

IN PERSON – Any PP&R facility is able to process your registration, including the Customer Service Center located in the lobby of the Portland Building at 1120 SW Fifth Ave. All Community Centers are open for walkin registration during business hours.

CHECK ONE:

 New Customer

 Taken class with PP&R before  My account information has changed

Main Contact Name _______________________________________________________________________ Birthdate ___________________________ M_____ F_____ African Immigrant White

American Indian/Alaska Native Slavic/Eastern European Immigrant

Black/African American Asian

Hispanic/Latino Multi-Racial

Native Hawaiian/Pacific Islander Other

Home Address ________________________________________________________________________ City/St/Zip _______________________________________________ Home Phone ( _________)________________________________________________ Work Phone ( _________)_________________________________________________ Cell Phone ( _________)_____________________________________________ Email Address _______________________________________________________________ Emergency Contact Name & Phone Number ___________________________________________________________________________________________________ Portland Parks & Recreation welcomes individuals with disabilities and special needs into programs. Please describe any accommodations needed for successful inclusion: _____________________________________________________________________________________________ PARTICIPANT INFORMATION Name (last, first)

Birthdate

M/F

Class Title

Course #

Class Location

NON-RESIDENTS of the City of Portland pay a 40% surcharge. Or you may purchase a non-resident pass at the amounts listed below. List pass price or 40% surcharge in column at right and add to your total.



I already have a non-resident pass. Duration ______-month Purchase date ______/______/______ Passholder name ________________________________________________________________________________________________

 I need a pass. Circle one: 3-month | 6-month | 9-month

Circle one: Individual | Family Name of person(s) needing pass ______________________________________________________________________________ 3-month pass: individual $25; family $50 | 6-month pass: individual $45; family $90 9-month pass: individual $65; family $130

Start Date

Cost

Subtotal 40% non-resident surcharge or pass price

TOTAL

 I do not want a pass. I choose to pay the 40% surcharge.

PAYMENT INFORMATION

 CHECK

Check number_____________________

 CREDIT CARD Account #

(make check payable to the City of Portland)

Information

____ ____ ____ ____

-

____ ____ ____ ____

- ____

____ ____ ____

Cardholder’s Name_____________________________________________________ Please print

- ____

____ ____ ____

Expires ____________________________________

Signature______________________________________________________________

 VISA  MasterCard  Amex

Registration Information

CIRCLE ONE:

1120 SW 5th Ave., Suite 1302 Portland, OR 97204 www.PortlandParks.org Address Service Requested