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1 Parent or Adult Participant Information Last Name First Name Last Name First Name Address Home Phone Work Phone City State Zip Resident Discount Card? Yes No (See below) Join our e-mail list for program updates: Emergency Contact (Other Than Parent) Last Name First Name Home Phone Work Phone Participant Medical Problems or Allergies, Special Needs or Accommodations: (Please use back of form if needed) Program Title Class Number Fee Please make checks payable to Parks & Recreation Total Participant's First Name Participant's Last Name Birthdate M/F Waiver/Medical Release: Upon registering and participating in this activity, I hereby release the City of Missoula Parks and Recreation Department, their employees or agents, and any person officially connected with their activities from liability or damages to my person or property arising from participation in or my presence at this activity. Further, I allow any first aid deemed necessary in case of injury. I understand and agree that the Missoula Parks & Recreation Department reserves the right to suspend a child/participant from a Parks & Recreation activity if that child displays a serious behavior problem that cannot be effectively managed by the program personnel. Further, I hereby grant permission to any and all of the foregoing to use any photos taken for this program without compensation for publicity use. #Responsible Person’s Signature: Date: For Office Use Only (Payment Information) Cash Amt Check # Check Amt Date Received Staff Initials Res Photo Paid Card Issued today: Yes No Card Mailed (date) Program Registration Form Enclose check or money order and mail to 600 Cregg Lane, Missoula, MT 59801 filename Parent (or Adult Participant) Parent (or Adult Participant) Parent (or Adult Participant) Parent (or Adult Participant) Gender If you are a City Resident and would like to purchase a $2 Resident Discount Card, please complete the form on the reverse.ª ---PAGE BREAK--- Resident Discount Card Application (Please print) NAME: DOB M / F NAME: DOB M / F NAME: DOB M / F NAME: DOB M / F NAME: DOB M / F ADDRESS: CITY: STATE: ZIP: Phone PROOF: Proof of residency in the form of a utility bill, vehicle registration, or voter registration. Amount Paid: Cash Amt Check # Check Amt Date Received Staff Initials Use this form to apply for a City Resident Discount Card. You must reside within City limits and provide proof of residency in the form of a utility bill, vehicle registration, or voter registration. Resident Discount Cards cost $2 per person and are renewable annually for Purchase a card for each family member who would like to receive the Resident Discount. Resident Discount is approximately 20% on most Parks and Recreation programs. Class Registration/Swim Pass Form On Reverse ª