Little Dragons Kung-Fu Class
REGISTRATION FORM
Print This Form, Fill It Out Completely and
mail to:
City of Lakewood
P.O.Box 158
Lakewood, CA 90714
Or deliver to Lakewood City Hall at 5050 Clark Avenue in Lakewood
You may also FAX your registration to: (562) 866-0505
or you may e-mail your registration to: www.lakewoodcity.org
Class # |
Last Name, First Name of Participant |
Age |
Class Name |
Day(s) |
Time |
Fee |
|
Total |
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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