REGISTRATION FORM

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					                          CITY OF            LAKE WORTH
                                             1121 Lucerne Avenue
                                             Lake Worth, FL 33460
                                        Telephone: (561) 533-7377 Ext. 4
  Recreation                                  FAX: (561) 533-7371
  Department



                                      REGISTRATION FORM

Register and pay for all youth and adult classes in person at the Recreation Department located at
1121 Lucerne Ave. or register by mail- just complete and send this form and fee (not responsible for
lost or indirect mailing) Complete refunds will be issued if class is cancelled or full. Please see refund
policy as stated below:
CHECKS PAYABLE TO: City of Lake Worth (do not mail cash)

REFUND POLICY:
THERE WILL BE NO REFUND AFTER COMPLETION OF THE FIRST DAY OF PROGRAM. PLEASE
ALLOW 4-6 WEEKS BEFORE REFUND IS MAILED TO YOU.

**NOTE RETURNED CHECK CHARGES: UP TO $50.00 FEE $25.00 $51.00-$300.00 FEE $30.00
OVER $300.00 FEE $40.00 OR 5% OF CHECK WHICHEVER IS GREATER.
-------------------------------PLEASE PRINT ALL INFORMATION---------------------------------------
Program________________________________________________ Fee $_________
Amount Enclosed $_____________ Check # __________ Cash __________
Participants Name_________________________________________________________
Date of Birth_________________ Age ________                   Male or Female (circle one)
Address ______________________________________ City______________________
State ________________________ Zip Code ___________Shirt Size_____________
E-Mail: ____________________________________________________________________
Home Phone _________________ Work Phone _____________Emergency Phone___________
Parent / Guardian_________________________________________________________
Emergency Contact ________________________________#________________________
Health / Medical Problems to be aware of: _____________________________________
THE UNDERSIGNED DOES HEREBY ASSUME ALL RISK OF DAMAGE/INJURY BY PARTICIPATING
IN ANY PROGRAM OR FIELD TRIP THROUGH THIS REGISTRATION AND AGREES TO HOLD
HARMLESS THE CITY OF LAKE WORTH, ITS AGENTS, FROM LIABILITY RESULTING FROM
PARTICIPATION.
_________________________________________________                    ______________
Signature of participant / parent or guardian (if under 18)            Date
 Detach and mail the registration form and check to :
                   City of Lake Worth “Program Registration”
                   Recreation Department
                   1121 Lucerne Avenue
                   Lake Worth, FL. 33460

→ WANT TO BE A STEP UP MEMBER? YES / NO ____________ INITIAL