Kearney Park & Recreation | Winter 2018-2019

4 WAYS TO REGISTER! Mail In, Phone-In, Walk-In, or Online (Begins Monday, December 3) PROGRAM REGISTRATION 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: 237.4644 Voice/TDD 233.3215 Method of Payment Cash Enclosed ______ Check Enclosed _____ Make Checks Payable to “City of Kearney” Visa ® ____ Mastercard ® ____ Discover ® ____ Credit Card # ___________________________________ Exp. Date_________ CCV# _______ ________________________________ __________________________________________________________________ __________________ ___________________ _________________________________________________ Family Name Primary Phone Work Phone Email __________________________________________________________________ __________________ ___________________ _________________________________________________ Address City State Zip Does the participant need any special accommodations in order to fully participate? ______ yes* ______ no Please designate any special needs you or your child may require *If yes, a follow-up call from KPR will be made. __________________________________________________________ NOTE: YOUWILL NOT BE MAILED AWRITTEN RECEIPT. ASSUME THAT YOU ARE IN THE ACTIVITY UNLESS OTHERWISE NOTIFIED. 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 assumption of risk. I do hereby absolve, release and agree to hold harmless the City of Kearney, it’s sponsors, leaders, agents and volunteers from liability claims in case of accidents to all 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 City of Kearney Park & Recreation Program. PARENT /GUARDIAN/ADULT PARTICIPANT SIGNATURE:_________________________________________________________________ DATE:______________________________________ PARTICIPANT’S NAME M/F AGE DATE OF BIRTH GRADE SCHOOL PROGRAM # ACTIVITY FEE $ $ $ $ $ TOTAL $ Official Use 3DIGITCODEONBACKOFCARD AUTHORIZEDSIGNATURE LEAGUE REGISTRATION MANY LEAGUES FILL FAST, REGISTER EARLY! Method of Payment Cash Enclosed ______ Check Enclosed _____ Make Checks Payable to “City of Kearney” Visa ® ____ Mastercard ® ____ Discover ® ____ Credit Card # ___________________________________ Exp. Date_________ CCV# _______ ________________________________ __________________________________________________________________ __________________ ___________________ _________________________________________________ Family Name Primary Phone Work Phone Email __________________________________________________________________ __________________ ___________________ _________________________________________________ Address City State Zip __________________________________________________________________ __________________ ___________________ _________________________________________________ Captain’s Name Primary Phone Work Phone Email Special Scheduling Request (not guaranteed) __________________________________________________________________________ NOTE: YOUWILL NOT BE MAILED AWRITTEN RECEIPT. ASSUME THAT YOU ARE IN THE ACTIVITY UNLESS OTHERWISE NOTIFIED. GOOD SPORTSMANSHIP: As a captain I am responsible for my team. I will recruit players who display good sportsmanship. I will be the spokesperson for my team and will follow all league rules and regulations at all times. REGISTRATION DEADLINES: Registration forms sent through the mail must be received by the registration deadline indicated. CAPTAIN’S SIGNATURE:________________________________________________________________________________________ DATE:___________________________________ SPORT LEAGUE (BE SPECIFIC) TEAM NAME FEE $ TOTAL $ Official Use 3DIGITCODEONBACKOFCARD AUTHORIZEDSIGNATURE RETURN COMPLETED FORM WITH FEE TO: Kearney Park and Recreation Dept., P.O. Box 1180, Kearney, NE 68848 Phone: 237.4644 Voice/TDD 233.3215

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