Little Dragons Kung-Fu Class


Print This Form, Fill It Out Completely and mail to:
City of Lakewood
P.O.Box 158
Lakewood, CA 90714


Class #

 Last Name, First Name of Participant


Class Name







Refunds are accepted if received before the second class meeting. There is a $5 administrative fee for refunds. I, the undersigned parent or guardian, do hereby agree to allow the individual(s) named herein to participate in the aforementioned activity(ies) and further agree to indemnify and hold harmless the City of Lakewood, its agents and employees from all harm, accident, personal injury or property damage which may be suffered in the aforementioned individual(s), arising out of, or in any way connected with participation in this activity.

Signature: _____________________________________________ Date: __________________ 
Payor: __________________  Method of Payment : ___Check ___Credit Card ___Money Order ___Cash
Address: ___________________________________________ Day Phone: _________________

City: _____________________________Zip:___ ______________Night Phone:_________________________
Person to notify in case of emergency: ______________________   Emergency Phone:__________________
____ Mastercard   ____Visa
Card Number:  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __
Expiration Date:  _____________
Name as it appears on the card: ___________________________________________________
Signature: _____________________________________________________________________

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