SOCCEROPOLIS  CLASSES

REGISTRATION LOCATIONS Santa Monica Swim Center 2225 16th St. Santa Monica 90405   Community Classes Office / Ken Edwards Center 1527 4th St., #101 Santa Monica, CA. 90401 Phone: (310) 458-2239   Reed Park Office 1133 7th St. Santa Monica 90403 Register via Email: recenroll@smgov.net (Print, Sign, and Scan)        Register via Fax: (310) 899-0840 (Print, Sign, and Fax) If you are paying by CHECK - Please make checks payable to : THE CITY OF SANTA MONICA. If you are paying by CREDIT CARD (VISA/MASTERCARD/DISCOVER) Cardholder Name : Cardholder Signature : _______________________________________ Card # Expiration Date :  Total amount :

Waiver, Release and assumption of risk in consideration of the applicant's participation in the above activity. I waive and release all claims for damages for death, personal injury or property damage that may occur as a result of engaging in that activity. This discharges in advance the city of Santa Monica, its employees and other agents from liability even though that liability may arise out of their negligence. I know that this activity involves a risk of accidents and i willingly assume the risk. This waiver, release and assumption of risk are binding on my heirs and assigns. I give permission for any medical care that the leaders of the above deem necessary. I also agree to accept full responsibility financial and otherwise, for the conduct of my child. i understand that this is no refund should my child be dismissed from class for improper conduct.   I hereby consent to the photographing,recording or reproduction in any other manner(including use of videotapes and audiotapes) of the likeness, voice and/or activities of my child and further authorize the city of Santa Monica, its agents or assigns, to make unlimited use of such reproductions, including, but not limited to broadcasting to the public of the reproductions over radio and televiosion stations. I understand that i will not receive any monetory compensation, now or in the future, for participating. i do hereby release and hold harmless the city of Santa Monica, its officers and employees, from any claims. My signature below indicates that i have read and fully agree with all registration policies stated herein : Parent Signature : ____________________________________________ Date : Class session # : Child's Full Name : M F Date Of Birth : Age : Street Address : City : State : Zip : Home Phone # : Work Phone # : Cell Phone # : Email : Emergency Contact Name : Emergency Phone # : Physician : Physician Phone # : * Refund Policy : Due to large volume of enrollments, we do not grant refunds, transfers or credits