Fillable 4679 City Of Huntington Park – Department of Parks and Recreation

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4679 City Of Huntington Park – Department of Parks and Recreation

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REV. 1/12
City of Huntington Park • Department of Parks & Recreation
3401 E. Florence Ave. • Huntington Park, CA 90255 • 323-584-6218 • FAX 323-584-6310
www.huntingtonpark.org
ADULT SPORTS REGISTRATION FORM
Manager’s Name (Last) ___________________________(First) ________________________ (MI) _____
Address _____________________________________________________________________________
(Street) (City) (State/ZIP)
Phone Number: ( ) _______________ ( )_________________ ( ) ___________________
(Home) (Cell) (Emergency)
E-mail Address ____________________________________________
Asst. Manager’s Name (Last) ________________________(First) ______________________ (MI) _____
Phone Number: ( ) _______________ ( )_________________ ( ) ___________________
(Home) (Cell) (Emergency)
E-mail Address ____________________________________________
Registering for (Check One)
Men's Basketball (Fri) Men’s Softball (Tues) Coed Softball (Mon) Coed Softball Tournament
Men’s Basketball (Sun) Men’s Softball Tournament Coed Softball (Wed) Volleyball Tournament
Team Name: _____________________________
Spring Summer Fall Season (Check one): Winter
League Fee: $______________ Forfeit Deposit: $ _____________ TOTAL FEE: $ __________________
I, the undersigned, do hereby agree to allow the individual(s) named herein to participate in the above mentioned program/activities and hereby
waive, release and discharge any and all claims of the right to claim for damages for death, personal injury or property damage which may have,
or which may hereafter occur to me, as a result of said minor’s participation in said activity. This release is intended to discharge in advance the
City of Huntington Park, its officers, employees, agents, game officials, managers and coaches from and against any and all liability arising out of
or connected in anyway with said minor’s participation in said activity, even though that liability may arise out of negligence of carelessness on the
part of the persons or entities mentioned above. I further understand that serious accidents occasionally occur during said activity, and that
participants of such activity occasionally sustain mortal or serious personal injuries, and/or property damage, as consequence thereof: Knowing
the risks of said activity, nevertheless, on behalf of said minor child, I hereby agree to assume those risks and to release and hold harmless all of
the person’s entities mentioned above who, through negligence and carelessness, might otherwise be liable to me, or my heirs of assigns for
damages. I further permit the use of activity/event photography and/or video taping for promotional use of the City of Huntington Park’s Web site,
brochures and public television. It is further understood and agreed that this wavier, release and assumption of risk are to be binding on my heirs
and assigns. I agree to accept and abide by the rules and policies of the City of Huntington Park, Department of Parks & Recreation. This
authorization shall remain in effect for all activities related to the above unless otherwise individuated or revoked in writing and delivered to said
agent. The undersigned agrees that this Agreement, Release and Indemnity is intended to be as broad and inclusive as permitted by the laws of
the State of California, and that if any portion of this document is held invalid, it is agreed that the balance shall, notwithstanding, continue in full
legal force and effect.
I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS
CONTENTS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY
AND I SIGN IT BY MY OWN FREE WILL.
Participant’s name: __________________________________________
(Parent or legal guardian for participants under 18 years old))
Participant’s signature: _______________________________________
(Parent or legal guardian for participants under 18 years old))
Date: ________________
**Make check(s) or money order payable to: City of Huntington Park**
Driver’s License # ____________________________
(If paying by check)
FOR OFFICE USE ONLY
Yes No
Birth Certificate
Code of Conduct
Immunization
Check # _________________
Money Order # ___________
Visa or MasterCard (circle one)
Receipt # ________________
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REV. 1/12
CONSENT TO TREATMENT
The undersigned hereby authorizes the City of Huntington Park, in the event of an emergency as agent for the
undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital
care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician
and surgeon licensed under the provisions of the Medicine Practice Act, whether such diagnosis or treatment is
rendered at the office of said physician or at said hospital.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being
required but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any
and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best
judgment may deem advisable.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.
Participant’s signature: Date:
(Parent or legal guardian for participants under 18 years old))
Family Doctor: Telephone: ( )
Insurance Co.:
Pertinent medical problems (epilepsy, diabetes, allergies) please list and explain all:
REFUND POLICY
100% refund for cancellation due to medical reason with doctor’s note, or for class cancelled by city.
100% refund minus $5 processing fee for any cancellation prior to second class meeting, second team practice
(youth sports), or at least one calendar week prior to first league game (adult sports).
*No refunds after second class meeting.
*No refunds after second team practice (youth sports only).
*No refunds less than one calendar week prior to first league game (adult sports only).
* NOTE: All refunds must be requested in-person at the Department of Parks & Recreation prior to the second class
meeting, second team practice (youth sports), or at least one calendar week prior to first league game (adult sports).
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4679 City Of Huntington Park Department of Parks and Recreation

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Completed 13 July 2020

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