City of Half Moon Bay
Recreation Division
Ted Adcock Community Center, 535 Kelly Ave, Half Moon Bay
Class Registration Form
Parent/Main Contact Information
Last Name:
First Name:
Address:
Phone Number:
Email:
Emergency Contact:
Phone:
Participant Name
Date Of Birth
Class Name
Class Dates Class Time Class Fee
I wish to donate to the Rollie Wright Scholarship Fund to help ensure all families in Half Moon Bay have access to
quality recreation programming $
Total $
I understand that photographs may be taken of me or my child during the course of said activity, and that these photographs
maybe used in the City of Half Moon Bay’s publications.
PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH. AMONG OTHER THINGS, IT LIMITS YOUR RIGHT TO SUE SHOULD
YOU OR YOUR CHILD BE INJURED WHILE PARTICIPATING IN A CITY PROGRAM.
Waiver and Release: I specifically acknowledge that City recreation programs may include physical activity that can result in injury
to participants, and I agree that should I engage in such activity that I do so voluntarily and at my own risk. THE UNDERSIGNED, in
consideration of participation in this recreation program and the use of the City of Half Moon Bay’s facilities, premises, equipment
and transportation services, hereby agrees to RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE THE CITY OF HALF
MOON BAY, its officers, employees, and agents (collectively, “the City”) for any loss or damage, and any claimor demands therefore
on account of injury to the person or resulting in the death of the undersigned, whether caused by the negligence of the City or
otherwise, while the undersigned is in, upon, or about the premises or any facilities or equipment therein or, arising out of, or in the
course of any transportation provided by the City.
In addition, the undersigned hereby agrees to indemnify and save and hold harmless, and defend at its own expense, the City from
any loss, liability, damage or cost, including reasonable attorney’s fee, the City may incur due to the presence of the undersigned,
in, upon, or about the City premises or in any using any facilities or equipment of the City whether caused by the negligence of the
City or otherwise.
If this agreement is signed on behalf of a minor by a parent or guardian, the phrases “I” and “the undersigned” in the previous
paragraph refer to the child and not to the parent or guardian signing on the child’s behalf. In the case of an injury to my minor child,
I authorize the City staff to administer minor first aid. In the event that I cannot be contacted and it is necessary to administer
further medical treatment, I will take full responsibility for any medical expenses.
I HAVE READ AND VOLUNTARILY SIGN THIS RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT.
I HAVE READ THIS RELEASE.
Signature:
Date:
FOR OFFICE USE ONLY
Date Entered:
Cash Credit Check #
SEND TO:
Half Moon Bay, Recreation Division, Ted Adcock Community Center,
535 Kelly Ave, Half Moon Bay, CA 94019
