b'MANY PROGRAMS FILL FAST,REGISTER EARLY! RETURN COMPLETED FORM WITH FEE TO: Kearney Park and Recreation Dept., P.O. Box 1180, Kearney, NE 68848//Phone: 237.4644Voice/TDD 233.3215 ___________Discover ___________ Credit Card # _______________________________________________________Exp. Date ______________________ CCV# _______________________________________________________________________________________________ AUTHORIZED SIGNATURE _____________________________________________________________________________________________________________________ PRIMARY PHONE _____________________________________________________________________________________________________________________ WORK PHONE _____________________________________________________________________________________________________________________ EMAIL Please designate any special needs you or your child may require. ______________________________________________________________________________________________________________________ FEE SCHOOL ACTIVITY TOTAL ___________________ PARTICIPANT RELEASE STATEMENT: We understand the activities that my family has enrolled in, and I hereby give my permission and consent for their participation.Furthermore, I recognize that proper care of equipment, fields and adequate supervision will be provided, but that inherent in these activities is a degree of an assumptionOFFICIAL USE of risk. I do hereby absolve, release and agree to hold harmless the City of Kearney, its sponsors, leaders, agents and volunteers from liability claims in case of accidents toall family members enrolled in these programs. PHOTO PERMISSION: We the parents or participating individual, do hereby grant permission for pictures and video to be used in publicity or brochures related to the Cityof Kearney Park & Recreation Program. PARENT /GUARDIAN/ADULT PARTICIPANT SIGNATURE:______________________________________________________________DATE:_______________________ REGISTRATION___________ Mastercard # PROGRAMprogram registration Method of Payment: Cash Enclosed ___________Check Enclosed ___________Make Checks Payable to City of KearneyVisa 3 DIGIT CODE ON BACK OF CARD _____________________________________________________________________________________________________________________ FAMILY NAME _____________________________________________________________________________________________________________________ ADDRESS _____________________________________________________________________________________________________________________ CITY, STATE ZIP Does the participant need any special accommodations in order to fully participate?NO *If yes, a follow up call from KPR will be made.YES*___________ M/F AGE DATE OF BIRTH GRADE PARTICIPANTS NAME NOTE: YOU WILL NOT BE MAILED A WRITTEN RECEIPT. ASSUME THAT YOU ARE IN THE ACTIVITY UNLESS OTHERWISE NOTIFIED.___________PG.37'