Pullman Parks & Recreation Guide

Fall 2017

Pullman Parks & Recreation Brochure...Your Recreation Connection

Issue link: http://digital.nexsitepublishing.com/i/862578

Contents of this Issue


Page 49 of 51

Pullman Parks & Recreation: Pioneer Center, 240 SE Dexter Phone: 509-338-3227 Register online at: PullmanParksandRec.com Fax: 509-338-3313 50 50 REGISTRATION/CARE-TO-SHARE FORM REGISTRATION/CARE-TO-SHARE FORM LIABILITY AND MEDICAL RELEASE AGREEMENT: I, the undersigned adult, on behalf of myself and my child(ren) assume all risks and hazards reasonably related to the conduct of the program, and/or rental or use of any City of Pullman facility. Further, I do hereby release and hold harmless the City of Pullman, its elected and appointed offi cials and employees, organizer, sponsor, supervisor, contracted facilitator, or any volunteer connected with a program, facility rental and/or use, from any and all claims, injuries, damages, losses and suits, including attorney fees, arising out of or in connection with the program or rental and/or use of a City of Pullman facility. I acknowledge that I have familiarized myself with the description of the activity(ies), rental or use of a facility, and understanding the hazards, myself and my child(ren)'s personal limitations, and knowingly assume all risks. In the event of a medical emergency, I authorize transportation to the nearest appropriate medical facility, and authorize emergency medical care if no one listed on the MIF (Medical Information Form) can be reached. If applicable, I authorize City of Pullman program facilitators, to administer medication to my child as outlined on the MIF form, and release from all liability said facilitators for any injury resulting from the administration of those medications, provided all medications are administered in accordance with the schedule and conditions. In the absence of a signature, payment of fee and participation in the program or use of a facility shall constitute acceptance of the conditions set forth in this release. PHOTO: I grant full permission to use any photographs, videotapes, motion pictures, recordings or any other record of this program for any City of Pullman informational or promotional use. REFUNDS: All refunds may be subject to a $10 service fee. (See full refund policy on page 44) CREDIT CARD/DEBIT CHARGES: I agree to pay above total amount according to card issuer agreement. X Signature (Participant or Parent/Guardian) Date Register Online at: PullmanParksandRec.com Mail: Parks & Recreation, 240 SE Dexter, Pullman, WA 99163 E-mail: recreation@pullman-wa.gov Fax: 509-338-3313 Payor Information: Fill form out completely (Please print clearly, using blue or black ink) First name: Last name: Home/Cell phone: Mailing address: Cell/Work phone: City: State: Zip: E-mail: Participant Information: Fill form out completely (Please print clearly) Participant's Name: Birthdays Gender Grade Activity Location Start Date Time Day of week Fee Jane Doe (Example) 1/25/09 M/F 2nd Sports Camp City Playfield June 9 3:15pm MWF $35 Please make checks or money orders payable to: City of Pullman (Do NOT mail cash) TOTAL $ C a r e - t o - S h a r e S c h o l a r s h i p Assistance is available for youth through 17 years of age interested in participating in Parks & Recreation programs and who reside in the Pullman School District, Senior Adults 60 years of age and older, and disabled adults who reside within the City of Pullman. Care-to-Share is based on a 50% match: one activity enrollment is allowed per person per brochure up to $20 or half of the activity fee, whichever is less. To be eligible, you must be receiving assistance through one of the following programs: free school lunches, Food Stamps, Income Assistance AFDC/TANF, energy assistance, medicaid, or subsidized housing (verifi cation needed for assistance to be granted). To apply: mail or bring this completed form with your verifi cation to Pullman Parks & Recreation, 240 SE Dexter, Pullman, WA 99163. Care-to-Share cannot be processed at any other location. We will notify you within one business day of the amount you are eligible to receive. No program space is guaranteed until actual enrollment into a program. Payment Information: Check: # Make check payable to: City of Pullman Credit Card: Visa MasterCard Card # - - - Expiration Date: / Security Code (found on the back of your card) Card Holder Name: We are currently receiving one of the following forms of assistance and authorize Pullman Parks & Recreation to verify "Free School Lunch" or we will provide proof of our eligibility for the "Care-to-Share" program. Parent/Guardian/Participant Signature ____________________________________ __Free School Lunch __Income Assistance AFDC/TANF __Food Stamps __Energy Assistance __Medicaid __Subsidized Housing For offi ce use only Date: Authorized by: Last received: Approve amount: C A n w y t o u C A i w y t o A

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