REGISTRATION Form Participant 1 Information Participant 1 Name: ___________________________________________ Birth Date: ___________________________ Gender: Male Female Email: ___________________________________________________ Address: __________________________________________________ City: ________________________ State: ________Zip:______________ Phone: ___________________________________________________ Gold/Silver Card Member: Yes No Program Registration Program Name: _____________________________________________ Location: _________________________________________________ Program Name: _____________________________________________ Location: _________________________________________________ Participant 2 Information Participant 2 Name: ___________________________________________ Birth Date: ___________________________ Gender: Male Female Email: ___________________________________________________ Address: __________________________________________________ City: ________________________ State: ________Zip:______________ Phone: ___________________________________________________ Gold/Silver Card Member: Yes No Program Registration Program Name: _____________________________________________ Location: _________________________________________________ Program Name: _____________________________________________ Location: _________________________________________________ Payment Information Total Fee: $ _____________ Payment Method: Cash Check (make payable to Parkway-Rockwood Community Ed) Credit Card ( Discover MasterCard Visa ) Card Number: ______________________________________________ Exp Date: _____________ Three-Digit Security Code: ____ Mail form and payment to: Parkway-Rockwood Community Ed, 1401 Froesel Drive, Ellisville, MO 63011 1. I hereby acknowledge that I understand the nature of the Program, and believe that I am qualified and in proper physical condition to participate in the Program. I further agree that if at any time, I believe my participation in the Program is unsafe with respect to my physical condition, the equipment, or facilities, it shall be my responsibility to immediately discontinue my participation in the Program. 2. I further acknowledge that I am aware that participation in the Program involves the risk of illness, serious bodily injury (including the possibility of permanent disability, paralysis, or death), which may be caused by (a) my own actions or inactions, (b) the actions or inactions of others participating in the Program, (c) the condition of the equipment and/or facilities at which the Program is located, or (d) the actions or inactions of the entities and persons identified below; and I fully accept and freely assume all such risk and all responsibility for losses, costs, and damages I may incur as a result of my participation in the Program. 3. I acknowledge and agree that the Parkway-Rockwood Community Education Program may revise its procedures at any time in accordance with guidance and protocols issued by the Centers for Disease Control and Prevention, the Missouri Department of Health and Senior Services, the Missouri Department of Elementary and Secondary Education, and the St. Louis County Department of Public Health, due to a spread of a contagious or spreadable illness, including the participation restrictions set forth above, and further agree to comply with the Parkway-Rockwood Community Education Program’s procedures at all times during my participation in the Program. 4. Accordingly, I hereby release and forever discharge, and waive the right to pursue any and all claims against the Parkway and Rockwood School Districts, together with their Boards of Education, officers, employees, volunteers, and agents (collectively, the “Releasees”) of, from, and against all liability, claims, demands, losses, or damages for any death, illness, personal injury, or property damage arising out of or resulting from my participation in the Program, even if such death, illness, injuries, or property damage are alleged to be in whole or in part directly or indirectly the fault of or caused by the negligence or carelessness of the Releasees. I further agree that if, despite this release and waiver of liability agreement I, or anyone on behalf of myself, makes a claim released in this agreement, I will indemnify and hold harmless each Releasee from any and all litigation expenses, attorney fees, loss, liability, damage, or cost they may incur as the result of such claim. 5. I agree that in an emergency, any Parkway or Rockwood representative may transport or authorize the transportation of myself to a hospital/medical facility and I authorize any physician or other medical personnel to carry out any diagnostic procedures or emergency care deemed necessary. I understand that the cost of medical attention and ambulance are my responsibility. 6. I acknowledge I may be required to provide any pertinent information concerning myself (i.e. allergies, health conditions, disabilities, special needs, etc.). I acknowledge that without full disclosure of my needs, the Parkway-Rockwood Community Education Program may not be prepared to ensure my success and safety in the Program. I acknowledge that information about myself provided in this registration may be used by a Parkway or Rockwood representative or any individual or organization identified by the Parkway-Rockwood Community Education Program as needed in order to effectively execute the Program. I acknowledge my registration in the Program may not be activated until all pertinent information has been submitted to Parkway-Rockwood Community Education. 7. I acknowledge and agree to the fees as outlined in this registration and that I am not accepted in the Program until I receive confirmation from Parkway-Rockwood Community Education. 8. I acknowledge that from time to time, a Parkway-Rockwood Community Education employee/designee may photograph or videotape myself while involved in a Parkway-Rockwood Community Education Program or activity. These photographs or videotapes will solely be used by Parkway and Rockwood for the promotion and marketing of programs and activities and will not be sold. I understand that it is my responsibility to notify the Parkway-Rockwood Community Education Program in writing if I do not wish to be photographed or videotaped. Participant 1 Signature: _________________________________________________________________________Date:__________________ Participant 2 Signature: _________________________________________________________________________Date:__________________ Please note: You cannot apply for Adventure Club with this form. You must apply online. Participation Waiver In exchange for the Parkway-Rockwood Community Education Program sanctioning the Program and providing district-paid staff members or other designees to supervise the Program, I hereby agree as follows: I have read this agreement as well as all Parkway-Rockwood Community Education, Parkway and Rockwood School District regulations, policies, procedures and consequences, fully understand its terms, and have voluntarily entered into this agreement of my own free will based only upon the terms and conditions included herein. 25 Questions? Email [email protected]
