Class Registration Form

REGISTRATION FORM

Print This Form, Fill It Out Completely and mail to:
City of Lakewood

• or you may e-mail your registration to: www.lakewoodcity.org

Class #

Last Name, First Name of Participant

Age

Class Name

Day(s)

Time

Total

Refunds are accepted if recieved before the second class meeting. I, the undersigned parent or guardian, do hereby agree to allow the individual(s) named herin to participate in the aforementioned activity(ies) and further agree to indemnify and hold harmless the City of Lakewood, its agents and employees from all harm, accident, personal injury or property damage which may be suffered in the aforementioned individual(s), arising out of, or in any way connected with participation in this activity.

Signature: _____________________________________________ Date: __________________
Address: ___________________________________________ Day Phone: _________________
City: _____________________________Zip:___ ______________Night Phone:_________________________
Person to notify in case of emergency: ______________________ Emergency Phone:__________________
____ Mastercard ____Visa
Card Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Expiration Date: _____________
Name as it appears on the card: ___________________________________________________
Signature: _____________________________________________________________________

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