City of Cape Girardeau
Parks & Recreation Department

Recreation Program Registration Form

Name

 

 Phone

 

 Business Phone

 
Address

 

 City

 

 Birthdate

 

 Age

 
Activity  
Date  
Location  
Time  
Session (Circle One): I II III IV V VI
Swim Level: 1 2 3 4 5 6 7 Unknown
Day (Circle One): M Tu W Th F Sa Su
In Case of Emergency Contact: ___________________________
Name: ______________________ Phone: _____________________

Waiver for Participant by Parent

In consideration of your accepting my child's entry, I hereby, for myself, my child, my heirs, executors and administrators, waiver and release any and all rights and claims for damages I or my child may have against the above park district or school district and its representative, successors and assigns for any and all injuries suffered by myself or my child at any activity sponsored by these groups.

Signature _____________________________________
Fee Paid Date _____________________________________
Received By _____________________________________
___ Check # ________ ___ Cash
Send Registration Form To:

City of Cape Girardeau
Parks & Recreation Department
A.C. Brase Arena
Cape Girardeau, MO 63701
Phone 573-335-5421