Registration Form - City Of Auburn Hills printable pdf download

The City of Auburn Hills-Registration Form

1827 N. Squirrel Rd., Auburn Hills, MI 48326 248-370-9353

If shirt is included - please indicate shirt size: Youth ___ S ___ M ___ L / Adult ___ S ___ M ___ L ___ XL

Name _______________________________________________________________________

Male or Female (Circle one)

Address_________________________________________________________City______________________________________ Zip_______________

Telephone-Home __________________________________ Work_________________________________ Cell __________________________________

School_____________________________________________ Current Grade: __________ Age:__________Birthdate: ____________________________

Email address _____________________________________________ Emergency contact ____________________________ Phone # _______________

Activity Name_________________________________________ Activity # _________________________ Day___________________ Time___________

Activity Start Date____________________ # of Weeks_______________ Location _________________________________________________________

Medical/Physical Limitations?_________________________________________ Medication: __________________________________________________

I/We understand the nature of the physical demands of this activity and the policies set forth by the Auburn Hills Recreation Dept. I have noted any medical/

physical limitations that might affect participation. I/We hereby release the City of Auburn Hills, the Auburn Hills Recreation Dept., and all of said entities’

employees, representatives and agents including, but not limited to, all individuals assisting in the instruction and/or supervision of their activities, from any

and all rights claims, demands, actions, and/or lawsuits for any and all injuries, loss or damage suffered by myself, my child(ren) and/or other family members

while participating, watching or traveling to or from this activity.

____________________________________________________________________________________________________________________________

Signature

Date