LGS | Recreation Winter/Spring 2019 Recreation Guide

One Form Per Household Feel Free to Copy Form or Register Online at www.LGSRecreation.org To Register Online at www.LGSRecreation.org • Fax to 408-775-8366 Drop off this form through the mail slot in the front door of our main office at 123 E. Main Street, Los Gatos, CA 95030 Office Hours: Monday – Friday, 8:00AM – 5:00PM Last Name First Name Home Phone Mobile Phone Address City Zip Email Address (required) Student First Name Student Last Name Student Birthdate Signature Date of wavier Indemnification: In consideration of participation in the programs operated by Los Gatos-Saratoga Community Education and Recreation (LGS Recreation), I agree to indemnify and hold harmless LGS Recreation, its Board of Directors, contractors, employees and volunteers, and release them from any and all liability, for any injury or harm which may be suffered by participants listed, including minors, on whose behalf this form has been signed (hereafter “my child”), arising out of, or in any way connected with, participation in any program operated by LGS Recreation. I have read this application and agreement, and fully understand that I assume all risks for any injuries received by my child. I also agree to indemnify LGS Recreation against any claims made arising out of any acts, errors or omissions of any participant listed below. I certify that I have custody or am the legal parent or guardian of my child, and that my child is physically able to participate in recreation activities. In the event my child requires medical treatment while under the supervision of staff and/or agents, I authorize said staff to provide and/or authorize medical treatment. I expect staff to contact me immediately in the event emergency medical treatment is required for my child, but this contact is not necessary to administer emergency aid. I will bear financial responsibility for all medical treatment which my child may require. Model Release: I release LGS Recreation and any photographer retained by it from liability for any violation of any personal or proprietary right I have in connection with any reproduction of or use of photographs in which I or my child appear. I consent to the reproduction or use of photographs, without my name (or those of other registered participants) taken of me or my child while participating in LGS recreation programs. I hereby grant permission to include pictures and/or video of me and/or my child while participating in LGS recreation program, for brochures or other publicity efforts. LGS Recreation and its photographer will only take photographs and videos in a public setting in which there is a reasonable expectation of privacy. I understand I will not receive any compensation for use of such pictures or video. This Waiver of Claims/Assumption of Risk/Consent applies to future participation in all programs of LGS by all signatories and children on whose behalf it has been signed. Refunds and Transfers are permitted up to 5 business days before the start of program unless otherwise stated. There is a cancellation fee of $10 for classes up to $100 and $25 for classes over $100. Transfer Fee is $10. All fees are per participant, per program. Participants Name Gender Date of Birth (Child) Program Title Start Date Start Time Program Fee Last First M F $ M F $ M F $ M F $ M F $ M F $ M F $ M F $ Payment Options: Credit Card Check (payable to LGS Recreation) Cash (in person only) Credit Card Number: Total: $ Expiration Date: Name as it Appears on the Card: Authorized Signature 2 View Expanded Descriptions and Register Online at www.LGSRecreation.org Questions? 408-354-8700 WINTER/SPRING 2019 REGISTRATION