FullGuideforWeb-spring19 - Page 43



Name
Phone
M/F
$
Fee
U. City website Other____________________________________________
TOTAL AMOUNT DUE
Tee Shirt Size
(if applicable)
Date _____________________________
_____________CHECK#________
______________MONEY ORDER
Resident
Non-Resident
Received by____________________________________________________________________________
STATUS VERIFIED (check all applicable boxes): Centennial Commons Member
12/14 LTE
_______________MC
______________VISA
mail in program reg form .lt
Date__________________________________________________________
Returned check fees: $25-Administrative Handling Fee PLUS $9-Bank Fee. Please note: Your home telephone number MUST be provided for ALL check (personal/cashier/certified) transactions.
TOTAL DUE: $_____________________ _____________CASH
--------------------------------------------------------------------------------------------------------------FOR OFFICE USE ONLY--------------------------------------------------------------------------------------------------------------------------------------
(If under 18, parent or legal guardian)
Print Name _______________________________________________ Signature_____________________________________________
By my signature below, I acknowledge and understand the City of University City exercises a HOLD HARMLESS POLICY during all sponsored classes, programs and events. This releases the City of University City, its agents, representatives, or employees from
any and all claims which may arise out of any accident or injury caused by the negligence of the City of University City, or its agents, representatives, or employees when participating in a program or event sponsored by the City of University City.
Rec Guide
Please indicate requested class/program, date(s) and time(s)
Program/Class/Activity
Please indicate below for each registrant: name, birthdate, sex, program/class or activity, and fee:
Birthdate
How did you hear about our classes, programs and events? Bulletin Board

Relationship
Cellular Phone
Please check appropriate boxes:
Resident
Non-Resident
Centennial Commons Member? yes no
The Department of Community Development-Recreation Division actively supports participation of all abilities, including people with disabilities, in its facilities, classes,
programs, and events. Please check “Yes” if you would like assistance to successfully participate. ___Yes, please have the Regional Coordinator of Inclusion Recreation
contact me. Please allow two (2) weeks prior to activity start date for coordination of support.
Emergency Contact
Email Address
Zip Code
MAKE CHECKS OR MONEY ORDERS PAYABLE TO THE CITY OF UNIVERSITY CITY
Work Phone

Home Phone
Address
PLEASE PRINT LEGIBLY AND COMPLETE ALL SECTIONS
ACTIVITY REGISTRATION FORM
DEPARTMENT OF COMMUNITY DEVELOPMENT
RECREATION DIVISION

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