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MailFaxorDropOffFormPaymentToCityofPortWashingtonParksRecreationDepartment201N.WebsterStreetPortWashingtonWI53074Phone262-284-5881Fax262-284-7678PORTWASHINGTONPARKSRECREATIONREGISTRATIONFORMPleasePrintHOUSEHOLDFIRSTNAME__________________________LASTNAME____________________________________STREET_________________________________________CITY_____________________________ZIP_________PHONEHOME__________________________________CELL________________________________________E-MAIL____________________________________________________________________________________________ProgramsheldoncitypropertyuseCityofPortWashingtonboundariesastheresidencyrequirementsforfees.ProgramsheldonschooldistrictpropertyusePortWashingtonSaukvilleSchoolDistrictboundariesastheresidencyrequirementsforfees.APortWashingtonmailingaddressdoesnotautomaticallymeanyouareacityresident.POOLPASSES-WhenpurchasingaFamilySeasonSwimPasslistallmembersreceivingapassintheparticipantssectionbelow.SHIRTSIZEifrequestedName_____________________YS68YM1012YL1416ASAMALName_____________________YS68YM1012YL1416ASAMALForPlaygroundProgram-IndicateParkLocation_______________________________________________________________SPECIALCONSIDERATIONSMedicationsdisabilitiesetc.______________________________________________________Pleaseconsiderthisregistrationformconfirmationofclassrequested.Wewillonlycontactyouintheeventofacorrectionorcancellation.ActivityNo.SectionNo.Participantx19sNameincludeLastNameifdifferentthanaboveChildx19sAgeGradeActivityNameDaysandTimesFeeVisaorMastercardCash__Check___________CreditCardNo.__________________________________________ExpirationDate____________TOTALFEE____________LIABILITYWAIVERItheundersigneddoherebyagreeoragreefortheabovenamedregistrantforwhomIamtheparentorguardiantoparticipateintheactivityindicatedandamawareofandunderstandthattheremayberisksandhazardsinherentwithparticipantsinthisactivity.IaffirmthatIortheminorregisteredforthisactivityamdoingsoasavoluntaryparticipant.Inconsiderationofmyparticipationorpartici-pationoftheminorIdoherebyagreetoreleasewaiveabsolveindemnityonbehalfofmyselforminormyhisherfamilymyhisherheirsandmyhisherassignstheCityofPortWashingtonitsemployeesoffi-cersagentsandsponsorsfromliabilityforinjurydeathorlosssufferedbymeortheminorinanyandallpresentandfutureclaimsliabilitiesdamagesorrightofactiondirectlyorindirectlyresultingoutofpartici-pationintheactivityusingthefacilitiesorengaginginanyactivitiesincidentaltheretoduringthedurationofthescheduledprogramwhichresultfromtheordinarynegligencefortheCityofPortWashingtonitsemployeesofficersagentsandsponsors.TheCityofPortWashingtondoesnotprovideaccidentinsurancetoparticipantsinrecreationalactivitiesandIassumeoragreefortheabovenamedregistrantforwhomIamtheparentorguardianfullresponsibilityforanyandallinjuriesordamageswhichmayoccurtomeortheabovenamedregistrantwhileparticipating.MEDICALEMERGENCYRELEASEWAIVERFORMINORSIntheeventofamedicalemergencyIauthorizetheParksandRecreationDepartmentStafftoobtainmedicaltreatmentformysondaughterorminorforwhichIamaguardian.PHOTORELEASEIagreetoallowpublicationofanyphotostakenatanyprogrameventorfacilityoftheCityofPortWashingtonParksandRecreationDepartment.XSignature______________________________________________________________Date_____________________________________Recx19dBy______________