Get AZ Youth Chess Classes - City of Douglas

Youth Chess Classes City of Douglas Special Events Division PLEASE PRINT Last Name First Name M. I. Address City State/Zip Phone evening Email Address Date of Birth Age Allergies/Med. Situations Contact Name emergency Phone emergency Event Code Event Name Date Location Fee YCC2013 Classes Spring Library GED Classroom Special Event/Program Registration Waiver Form We/I the undersigned assume all risks and/or hazards with participation in or connection with this or specified programs and do so hereby agree to hold harmless the City of Douglas or its employees from loss which may occur therein. I also hereby grant permission to City of Douglas staff members to administer first aid and contact proper emergency personnel and authorize medical treatment for me until the proper personal arrives. Youth Chess Classes City of Douglas Special Events Division PLEASE PRINT Last Name First Name M. I. Address City State/Zip Phone evening Email Address Date of Birth Age Allergies/Med* Situations Contact Name emergency Phone emergency Event Code Event Name Date Location Fee YCC2013 Classes Spring Library GED Classroom Special Event/Program Registration Waiver Form We/I the undersigned assume all risks and/or hazards with participation in or connection with this or specified programs and do so hereby agree to hold harmless the City of Douglas or its employees from loss which may occur therein* I also hereby grant permission to City of Douglas staff members to administer first aid and contact proper emergency personnel and authorize medical treatment for me until the proper personal arrives. I authorize my child to walk home I authorize to sign my child out I have read the registration procedures as outlined above. Signature Date Parent Guardian Participant Staff accepting registration form Date th 425 10 Street Douglas AZ 85607 520 417-7340. Address City State/Zip Phone evening Email Address Date of Birth Age Allergies/Med* Situations Contact Name emergency Phone emergency Event Code Event Name Date Location Fee YCC2013 Classes Spring Library GED Classroom Special Event/Program Registration Waiver Form We/I the undersigned assume all risks and/or hazards with participation in or connection with this or specified programs and do so hereby agree to hold harmless the City of Douglas or its employees from loss which may occur therein* I also hereby grant permission to City of Douglas staff members to administer first aid and contact proper emergency personnel and authorize medical treatment for me until the proper personal arrives. I authorize my child to walk home I authorize to sign my child out I have read the registration procedures as outlined above. I authorize my child to walk home I authorize to sign my child out I have read the registration procedures as outlined above. Signature Date Parent Guardian Participant Staff accepting registration form Date th 425 10 Street Douglas AZ 85607 520 417-7340. Address City State/Zip Phone evening Email Address Date of Birth Age Allergies/Med* Situations Contact Name emergency Phone emergency Event Code Event Name Date Location Fee YCC2013 Classes Spring Library GED Classroom Special Event/Program Registration Waiver Form We/I the undersigned assume all risks and/or hazards with participation in or connection with this or specified programs and do so hereby agree to hold harmless the City of Douglas or its employees from loss which may occur therein* I also hereby grant permission to City of Douglas staff members to administer first aid and contact proper emergency personnel and authorize medical treatment for me until the proper personal arrives. I authorize my child to walk home I authorize to sign my child out I have read the registration procedures as outlined above. Signature Date Parent Guardian Participant Staff accepting registration form Date th 425 10 Street Douglas AZ 85607 520 417-7340. .