Release of Liability: In consideration of the City of Cottage Grove allowing me (or my child) to voluntarily participate in the Parks and Recreation Program, 1. I agree to assume all risk of accidents
or damage in connection with my voluntary participation. 2. I acknowledge that certain activities of the program are inherently dangerous sports and/or subject me to personal injury with other
participants and/or equipment used in this activity. 3. I release and discharge the City of Cottage Grove, its agents, officers, employees, and insurers from any claim for negligent acts or omissions
occurring or arising out of my participation in this program. This waiver does not apply to any injuries or damages that are the result of any willful, wanton, or intentional misconduct by the City or
anyone acting on behalf of the City. 4. I agree to abide by all rules and regulations of the program. I further agree to wear protective clothing and equipment at all times, which clothing and equip-
ment shall be furnished at my own expense. 5. I acknowledge that my juvenile son/daughter may be videotaped or photographed during this activity and such videos or photos may be used by the
City for advertising purposes, and hereby grant permission for same. 6. I agree that this release is binding upon my spouse, parents, children, and heirs and assigns. This release does not extend to
or apply to any damage caused by willful, wanton or intentional misconduct. 7. I agree to abide by the Cottage Grove Recreation Department’s cancellation policy as posted on the City’s web site
www.cottagegrovemn.gov. 8. I understand that there may be additional fees assessed if I use a credit card on-line. 9. I have read this release and understand its contents. I understand that enter-
ing into and signing this agreement affects my legal rights and results in my giving up or waiving certain legal rights, and I accept this and sign this agreement of my own free will. 10. My signature
indicates I have read this entire document, understand it completely, acknowledge that it cannot be modified or changed in any way by oral representations, and agree to be bound by its terms.
Auto-Payment
Name: VISA: MC: AMX:
Credit Card Number: Exp Date: Sec. Code:
Adult Contact Information
First/Last Name:
Address:
City, State, Zip Code:
Phone 1/Name: Phone 2/ Name:
Phone 3/Name:
E-mail Address:
Cottage Grove Recreation Department ~ 8020 80th St. So., Cottage Grove, MN 55016
Phone: 651-458-3400 ~ www.cottagegrovemn.gov ~ Scan/email: mpietruszewski@cottagegrovemn.gov
Minnesota Data Practices Act: The information requested on this form will only be used to verify eligibility and determine staff, facility and equipment needs. Your/your child’s name, age, grade
level, address, telephone number, and health information will be provided to City staff, volunteers, the City attorney, insurer and auditor. Although you are not legally required to disclose this infor-
mation, failure to do so will prevent you/your child from participating in this/these programs.
I certify that I am the parent/legal guardian of the above-named participant and hereby consent to his or her participation in the program.
Signature of Parent/Legal Guardian:_____________________ Date:______
Participant Information - Please fill out one form for each participant.
First/Last Name: Date of Birth:
Gender: Special Needs/Medical Conditions/Allergies:
Park Preference:
Program Dates - $88 per Week or $22 per Day
June 7-11.................
June 14-18...............
June 21-25...............
June 28-July 2..........
July 6-9....................
July 12-16.................
July 19-23.................
July 26-30.................
August 2-6................
August 9-13..............
August 16-20............
M
T
W T
F
Auto-Pay: I hereby authorize “Active Net” to debit the weekly
payment owed to the City of Cottage Grove Recreation
Department, automatically on the weekly payment due date set
forth on my receipt from my below-described credit/debit card. The
City of Cottage Grove Recreation Department may cancel this
authorization at any time.
I may cancel or adjust this authorization by contact-ing The City of
Cottage Grove Recreation Department the preceding Thursday
before noon before the scheduled deduction.
I have the right to receive written notice at least ten days before the
scheduled date of a weekly payment debit if the debit will be different
from the payment set forth on my receipt.
I also agree that I will be billed an additional $12 per each 15 minutes,
or portion thereof, that my child remains at the supervised
playground past 4:30pm each day. Charges will be
automatically assessed to the below-described card.
Please enter any notes:
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signature
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