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Park & Recreation Dept

 Parent/Guardian Last Name
 First Name
Address
City
 State
 Zip

Resident:
Yes No

Phone
Home Work Other

Participant Name and Information
Activity
No.		 Section
No.		 Last Name First Name Age/Grade Activity Name
Days & Times		 Activity
Fee
            $
            $
            $
            $
Does participant require and special needs? Yes: No:
Total Fees: $
Swim Pass:   Park Pass   Location  
(For family pass - list all members of family in above spaces)
Form of Payment Cash: Check:

Make Checks Payable to:

City of Port Washington
Park & Recreation Department 284-5881
201 N. Webster Street
Port Washington, WI 53074

 Complete if paying by credit card
Circle:   or          Expiration Date: _____________
Credit Card Number: 
                                               

Signature: x __________________________________

I hereby register myself/my child to participant in the Activity/Class above named. In granting permission, I recognize that such activity may be hazardous and injury or accident may occur as a result of direct or indirect participation. Therefore, I agree to release the City of Port Washington, its employees, agents, and volunteer aids from liability as a result of accidents incurred while participating in the Activity/Class.

Signature of Participant/Parent or Guardian if under 18 years

 

 Date