APRC Fall 2017 PlayGuide | 541.488.5340 | The Grove at 1195 E Main St, Ashland • See p. 2 for registration schedule, options and refund policy • See p. 44 for complete instructions • Pre-registration is required for all activities except where noted • Activities are filled according to registration date—Register early—Help us avoid the cancellation of programs • Mail or bring your completed Registration Form with payment to: Ashland Parks & Recreation Commission at The Grove, 1195 E Main St, Ashland, OR 97520 Date of Birth ________________ Participant’s Name ________________________________________________________________________ M F (mm–dd–yyyy) Parent’s/Guardian’s Name (if under 18) _________________________________________________________________________________ Residential Address ____________________________________________________________________________________________________ City________________________________________________________ State _________________________Zip ________________________ Phone Numbers: Home ___________________________________ Work ________________________ Cell ________________________ E-Mail Address ________________________________________________________________________________________________________ Your email address is only used to provide you with instant confirmation and a printable receipt Emergency Contact Name ________________________________________________________________ Phone________________________ Activity/Session/Dates Amount _______________________________________________________________________________________________________$ _______________ _______________________________________________________________________________________________________$ _______________ _______________________________________________________________________________________________________$ _______________ Cash_______________ Make checks payable to: “APRC” Check#_____________ Total $ _______________ Credit Card Number ____________________________________________________________________(circle one) VISA M/C AMEX Name on Card (print)_________________________________Exp Date______________________ 3-Digit Security Code (on back of card) ______ Signature _________________________________________________________________________________ Date _______________________ PLEASE NOTE — PRIOR TO ENROLLMENT IN ANY ASHLAND PARKS & RECREATION ACTIVITY YOU MUST SIGN A CURRENT YEAR LIABILITY WAIVER. ONLY ONE LIABILITY WAIVER PER CALENDAR YEAR IS NEEDED. Liability Waiver (required): Name of Participant _____________________________________________________________________________________ I hereby certify that I am 18 years of age or older. If I am the parent or legal guardian of a participant who is under 18 years of age, I agree that the following provisions shall apply to that participation and agree to be fully bound by them. I understand that participation in the Ashland Parks and Recreation Commission (APRC) recreational activity involves risk of injury or death. Participant is not affected by any physical condition or disability that would make participation unsafe. I understand that APRC will not provide medical treatment, and I authorize APRC to arrange for any necessary transportation in the event of an accident or emergency. For myself, my heirs, assigns or anyone who might claim on my behalf, I voluntarily assume all risks of participating in this activity and I waive, release and forever discharge any claim against APRC, its officers, agents and employees against any claim, loss, liability or expense, including attorneys’ fees, that may directly or indirectly result from participation in this activity, even though that liability may arise out of the negligence or carelessness of the persons or parties named in this waiver and release. Signature (required) Date________________________ of Participant or Parent/Guardian if under 18 years of age Instructions registration form