Fillable Form 4683 Activity Registration Form (City Of Huntington Park)

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Form 4683 Activity Registration Form (City Of Huntington Park)

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3401 E. Florence Avenue Huntington Park, CA 90255 www.hpca.gov (323) 584-6218
Activity Registration Form
Name (Last): (First) (MI)
(Adult/Parent/Guardian)
Address:
(Street) (City) (State/ZIP)
Phone Number: ( ) ( ) ( )
(Home) (Cell) (Emergency)
E-mail Address: Birth Date:
(mm/dd/yyyy)
TOTAL FEE: $
I give permission for the minor in my custody 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**
Class/Activity/
Sport Name
Participant
Last Name
Participant
First Name
Sex
M/F
Birth Date
FOR OFFICE USE ONLY
Yes No
Birth Certificate
Code of Conduct
Immunization
Check # _________________
Money Order # ___________
Visa or MasterCard (circle one)
Receipt # ________________
3401 E. Florence Avenue Huntington Park, CA 90255 www.hpca.gov (323) 584-6218
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
No refunds after the second class meeting.
No refunds 48 hours prior to the first class meeting (for 1 day classes only).
No refunds after second team practice (youth sports only).
No refunds less than one calendar week prior to first league game (adult sports only).
100% refund for cancellation due to medical reason with doctor’s note, or for class cancelled by city.
For facility reservation cancellations, please refer to the Facility Rental Information Policy (Cancellations
Section)
100% refund minus $5 processing fee per transaction for any cancellation
* NOTE: All refunds must be requested in-person at the Department of Parks & Recreation and in accordance with
all refund policies.
I have read and fully understand the Department's Policy as it relates to Refunds.
Participant’s Signature:
(Parent or legal guardian for participants under 18 years old)
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Form 4683 Activity Registration Form (City Of Huntington Park)

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Completed 14 July 2020

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