Program Registration Form
Return completed form with fee.
Make check payable to:  JCPRD
ATTENTION:  Registration Office (Bldg. C)
6501 Antioch Road, Shawnee Mission, KS 66202

PLEASE PRINT

Participant's Name

 Age

Code Number

Program Title

Date

Day

Time

Fee
               
               
               

Note:  Please keep a record of dates and times of classes you have enrolled in, confirmations are not sent.

WAIVER STATEMENT:
"The undersigned states that he/she understands that the Johnson County Park and Recreation District is not and shall not be responsible for or liable for any illness, or injury to person or damage to property resulting form the program which the undersigned is enrolling or being enrolled or from his/her participating in said program, and the participant and the undersigned, if the participant is a minor or under other legal disability, hereby forever releases and holds harmless the said Johnson County Park and Recreation District, its employees, Agents and representatives from any and all claims of any kind that the participant, or the undersigned or their respective heirs, executors, administrators, or assigns may have or claim to have resulting from participation in said program.  Also, the undersigned and the participant authorize the Johnson County Park and Recreation District to use at its discretion any photograph(s) (black/white or color) taken of the participant while participating in the program and waive any and all claims that the participant or undersigned or the heirs, executors, administrators, or assigns may have or claim to have resulting from such photograph(s) or reproductions thereof."		 Please charge all fees to:   __MC         __VS

Card Number:_______________________ Expires:____________

Name as Printed on Charge Card:___________________________
   

JCPRD is committed to making reasonable accommodations as required by the Americans With Disabilities Act.  Requests must be made two weeks or ten working days prior to the start of the program.  Please indicate what accommodations are needed:____
____________________________________________.

I HAVE READ & UNDERSTAND THE WAIVER STATEMENT & CANCELLATION POLICIES; REGISTRATION INVALID WITHOUT SIGNATURE

x______________________________________     _______________
Signature of person registering                                                                           Home Phone #

_________________________
Work Phone #

Address:______________________________________________________________________________________
                         Street                            (Apt. #)                     City                                           State                             Zip (Required)
__PLEASE CHECK IF YOUR ADDRESS HAS CHANGED WITHIN THE LAST 18 MONTHS.
Previous Address:____________________________________________________________