The city's liability waiver and photo release portion must be signed by all parent/guardians or participants 18 and over. Registrations with unsigned waivers will not be processed. Thank you!

1. Primary contact (adult) Complete entire form

Name of primary contact:

Birthdate:

Street:

City:

Zip:

Email address:

Primary phone: ()

Secondary phone: ()

Cell phone: ()

Emergency contact:

Relationship to participant:

Emergency daytime phone: ()

Emergency evening phone: ()

2. Activity registration

Participant registration details for courses.
Participant's name (First & Last, 1 line per participant)	Date of birth (mm/dd/yy)	Course name	Course #	Fee
1. None	None	None	None	None
2. None	None	None	None	None
3. None	None	None	None	None
4. None	None	None	None	None
5. None	None	None	None	None
None	None	None	Total fees	$ None

Please note any allergies and/or medications:

[ ] I require an ADA accommodation due to a disability to participate in this program.

I wish to donate to the youth scholarship fund + $

Total $

3. Liability waiver & photo release

Hold harmless and release agreement: The undersigned on behalf of himself/herself and on behalf of any child enrolled by the undersigned in the program, in consideration of participation in this program, agrees to indemnify and hold harmless, and to release, waive, and discharge, the City of San Rafael against any claim, demand, suit, judgment, loss, liability or expense of any kind, including attorney's fees and administrative costs, on account of personal injuries or damages sustained by any person or property arising out of or in any way connected with participation by the undersigned or the enrolled child in this program, including injuries due to the active or passive negligence of the City, its officers, employees, agents, and volunteers. I have read the above hold harmless and release agreement and fully understand that I assume risks for any injuries and property damage suffered. I also certify that I (or my children) are knowledgeable as to all rules of conduct appropriate to the above-mentioned activity. Neither I nor my child has any physical illnesses, conditions, disabilities, or weaknesses that would interfere with safe participation in the activity. I recognize that bodily injury and/or property damage may be sustained through participation in this activity and acknowledge that I/we voluntarily accept all risks of injury to persons or property.

Applicant's signature:

Date: / /

Photo release: By initialing, I do also hereby give my permission to the City of San Rafael to use any and/or all photographs of myself and/or my children for future agency publications. I understand that my name or my children's name(s) will not be published at any time in any publications. I give my permission for a photograph of my child to be used for City of San Rafael marketing purposes. Initial

4. Payment

Credit card payments are processed through our online registration system at www.cityofsanrafael.org/recreation. You may also pay with credit card, check or cash in-person at our community centers.

San Rafael Community Center

618 B Street

Terra Linda Community Center

670 Del Ganado

Albert J. Boro Community Center

, 50 Canal Street