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Primary Member or Date / / Parent / Guardian Email New Households or Information Updates — Please leave this section blank if we already have your household information on file. Mailing Address City State Zip Primary Member Name Birthday: / / Female Male Home Phone Work Phone Cell/Other Phone Secondary Member Name Birthday: / / Female Male Home Phone Work Phone Cell/Other Phone Emergency Contacts 1. Name 2. Name Dependents Name B-day / / _ Name B-day / / Name B-day / / Name B-day / / Name B-day / / Name B-day / / For membership purposes, a family is defined as an individual, their spouse and any children living in the same household who are claimed as dependants according to IRS guidelines. Mailed and faxed activity registrations are welcome by credit card only and will not be processed until after walk-in registrations are completed (during registration periods). Name Activity Code Member Non-Member Name Activity Code Member Non-Member Name Activity Code Member Non-Member Name Activity Code Member Non-Member Name Activity Code Member Non-Member Name Activity Code Member Non-Member Name Activity Code Member Non-Member Name Activity Code Member Non-Member Please sign and date the Waiver Section on the reverse side of this form. REGISTRATION AND INFORMATION UPDATE FORM Paul Stock Aquatic and Recreation Center NEW HOUSEHOLD REGISTRATION • HOUSEHOLD INFORMATION UPDATE F M F M F M F M F M F M ACTIVITY REGISTRATIONS ---PAGE BREAK--- Requests to change bank account information must be received by the 9th of the month we process the EFT. Bank Name Routing # Account # Please attach a copy of a voided check (checking) or a bank letter. Print Member Name Signature of Account Holder Please cancel my Electronic Funds Transfer (EFT) contract agreement for my membership at the Paul stock Aquatic and Recreation Center as per the terms of the contract. I realize that I am still responsible for any payments remaining until my current contract expires. Print Name Signature of Primary Member Date Please read this waiver carefully, and let us know if you have any questions or concerns. When registering yourself, your spouse, or your minor child/children for membership and participation in activities and programs sponsored by the Paul Stock Aquatic & Recreation Center you will be waiving and realizing all claims for injuries you, your spouse, or your minor child/children might sustain arising out of the use of the facility mentioned above. I hereby give my consent for myself, spouse or minor child/children to participate in recreational activities sponsored by the Cody Parks & Recreation Department in Cody, Wyoming, during any session of the recreation program. I HEREBY RELEASE THE SHOSHONE RECREATION DISTRICT, RECREATION DIRECTOR, RECREATION STAFF AND BOARD OF DIRECTORS, THE CODY PARKS & RECREATION DEPARTMENT, THE CITY OF CODY, AND ALL CITY STAFF ASSOCIATED THEREWITH FROM ALL LIABILITY, INCLUDING CLAIMS AND SUITS AT LAW OR IN EQUITY FOR ANY INJURY FATAL OR OTHERWISE, INCLUDING BUT NOT LIMITED TO CLAIMS FOR NEGLIGENCE, while participating in any of the recreation activities and understand that I will be fully responsible for any damage or injuries incurred by the participant while involved in any Recreation Department activity. Also, I hereby pledge to provide positive support, care and encouragement for my fellow competitors and league officials by following this Code of Ethics. I will encourage good sportsmanship by demonstrating positive support for all players, coaches and officials at every game. I will treat other players, coaches, fans and officials with respect regardless of race, sex, creed or ability. I understand that I am participating in a recreation activity and agree not to use profane language or engage in ‘trash talking’ at any time. I will lead, by example, in demonstrating fair play and sportsmanship to all my fellow competitors. I understand that the officials are there for my benefit and will agree not to direct any profane or threatening actions toward them (either verbal or physical). I understand that any violation of this code shall be cause for the Shoshone Recreation Board & Cody Parks & Recreation, in executive session, to deal with any behavior and/or conduct that are considered by the Board to be disruptive, destructive, and/or illegal. Behavioral problems may result in expulsion from the program without reimbursements. The Shoshone Recreation District/Cody Parks & Recreation Department does not provide any medical insurance or personal liability to cover participants during an activity. This is the responsibility of each individual involved in any recreation activity. NOTICE: The City of Cody reserves the right to take and use photographs of individuals using the Cody Recreation Center and/or participating in programs sponsored by the City of Cody. Such photographs are the property of the City of Cody, and may be used in brochures, advertisements and other promotional materials. All purchased memberships are non-transferable and non-refundable. All purchases are subject to our return policy. Print Name Signature Date: Paul Stock Aquatic and Recreation Center Cody Parks, Recreation and Public Facilities 1402 Heart Mountain Street P.O. Box 2200 Cody, Wyoming 82414 (307) 587-0400 ELECTRONIC FUNDS TRANSFER (EFT) BANK ACCOUNT CHANGE ELECTRONIC FUNDS TRANSFER (EFT) CANCELLATION REGISTRATION AND INFORMATION UPDATE MEMBERSHIP AND ACTIVITY WAIVER ID copied by Initials Membership Expiration Date SIGN SIGN SIGN