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Olathe Parks and Recreation Summer 2014 : Page 66

Main Contact OR Parent: ____________________________________________ DOB _______________ Work Phone: (________) ______________________ Street ______________________________________________________ City ________________________________ State ________ Zip __________________ Home Phone: (________) ________________________ E-mail Address _____________________________________________________ ________________ Instructions: Please print and fill in forms completely. Unsigned forms can not be processed. If you are disabled, need special accommodations, please list your special needs in the appropriate space. Special needs requests must be made 10 working days prior to the start of the activity. Participants Full Name Needs/Comments/Coach/Shirt Size: 2nd choice (if above is not available) Participants Full Name Needs/Comments/Coach/Shirt Size: 2nd choice (if above is not available) DOB Grade M/F Code Activity Title Time Date LOCATION: Fee DOB Grade M/F Code Activity Title Time Date LOCATION: Fee School Attended: School Attended: General Information 66 Method Of Payment: Card Number: Cash o Check o MasterCard o Visa o Expiration Date: Fee Total: CVC Make Check Payable To: CITY OF OLATHE Mail To: Registration, Recreation Division, PO Box 768, Olathe, KS 66051-0768 Fax: 913-971-8690 The undersigned, understands that injuries are a natural part of many recreation activities and agrees to indemnify, hold harmless and release the City of Olathe, Olathe District Schools their agents and employees from any and all liability for any injury which may be suffered by the above named individual(s) registered in this activity arising out of or in any way connected with participation in this activity. The undersigned and participant authorize the City of Olathe and the Olathe District Schools to use at its discretion any photograph(s) taken of the participant for promotional purposes, including but not limited to print, online, and social networking media while participating in an activity and waive any and all claims that the participant or the undersigned or their heirs, executors, administrators, or assigns may have or claim to have resulting from such photograph(s) or reproductions thereof. I have read the above statement, understand and agree to the conditions set forth. Print Name __________________________________ Signature X __________________________________________ Participant o Parent/Guardian o --------------------------------------------------------------------------------------------------Main Contact OR Parent: ____________________________________________ DOB _______________ Work Phone: (________) ______________________ Street ______________________________________________________ City ________________________________ State ________ Zip __________________ Home Phone: (________) ________________________ E-mail Address _____________________________________________________________________ Instructions: Please print and fill in forms completely. Unsigned forms can not be processed. If you are disabled, need special accommodations, please list your special needs in the appropriate space. Special needs requests must be made 10 working days prior to the start of the activity. Participants Full Name Needs/Comments/Coach/Shirt Size: 2nd choice (if above is not available) Participants Full Name Needs/Comments/Coach/Shirt Size: 2nd choice (if above is not available) DOB Grade M/F Code Activity Title Time Date LOCATION: Fee DOB Grade M/F Code Activity Title Time Date LOCATION: Fee School Attended: School Attended: Method Of Payment: Card Number: Cash o Check o MasterCard o Visa o Expiration Date: Fee Total: CVC Code Make Check Payable To: CITY OF OLATHE Mail To: Registration, Recreation Division, PO Box 768, Olathe, KS 66051-0768 Fax: 913-971-8690 The undersigned, understands that injuries are a natural part of many recreation activities and agrees to indemnify, hold harmless and release the City of Olathe, Olathe District Schools their agents and employees from any and all liability for any injury which may be suffered by the above named individual(s) registered in this activity arising out of or in any way connected with participation in this activity. The undersigned and participant authorize the City of Olathe and the Olathe District Schools to use at its discretion any photograph(s) taken of the participant for promotional purposes, including but not limited to print, online, and social networking media while participating in an activity and waive any and all claims that the participant or the undersigned or their heirs, executors, administrators, or assigns may have or claim to have resulting from such photograph(s) or reproductions thereof. I have read the above statement, understand and agree to the conditions set forth. Print Name __________________________________ Signature X __________________________________________ Participant o Parent/Guardian o 913-971-8563 www.olatheks.org/ParksRec

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