Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
(must be returned with Camp Kaleidoscope, Mini Kaleidoscope, Adventure Camp and Ramp It Up registration and
to attend the Summer Playground Program)
Health History:
Food Allergies:__________________________________ Symptoms:____________________________
Diabetes:_______________________________________ Symptoms:____________________________
Medications:_________________________________________________________________________
Any other operations, serious injuries, chronic or recurring illnesses we should be aware of:
Important: Please notify the Recreation Leader if this participant has been
exposed to any communicable disease during the 3 weeks prior to
attendance or at any time during participation.
Parents’ Authorization: This health history is correct so far as I know, and the person herein described has permission to
engage in all prescribed activities, except as noted by me.
In the event I cannot be reached in an EMERGENCY, I hereby give permission to physician selected by parent or legal
guardian or the recreation leader to hospitalize, secure proper treatment for, and to order injection anesthesia or surgery
for my child, named above.
_____________________________________________ ________________________
Parent/Guardian Signature Date
For information on other City departments and special events go to www.sanbruno.ca.gov 55
Registration Information & Instructions
Registration begins immediately.
56 City of San Bruno 2011 Summer Community Services Activity Guide Call (650) 616-7180
Registration Form
Please fill out the form below and mail with your payment to:
Veterans Memorial Recreation Center
MAILING ADDRESS: 567 El Camino Real PHYSICAL ADDRESS: 251 City Park Way
San Bruno, CA 94066 San Bruno, CA 94066
650-616-7180 (phone)
650-583-2545 (fax)
Payer Name: _______________________________________________________________________________
(First Name) (Middle Initial) (Last Name)
Address:___________________________________________________________________________________
(City) (Zip)
Home Phone:( )________________ Day Phone:( )_________________ Emergency:( )_______________
Email address:_______________________________________________________________________________
Receive your receipt by email and be included in our regular email updates.
Participant’s Sex Birthdate Code Number Code Number Activity Program
Full Name Grade M/F (all participants) 1st Choice 2nd Choice Name Fee
Total Fees
Liability Release: In consideration of my application for the above activity, I
Release:
hereby waive, release, and discharge any and all claims for damage for death, It’s Easy! You can even use your credit card!
personal injury or property damage, which I may have, or which may hereafter KVisa KM/C
occur to me, as the result of participation in said event or activity. This release
is intended to discharge in advance the City of San Bruno, its officers, em- Signature
ployees, agents or volunteers from liability, even though that liability may _______________________________
arise out of negligence or carelessness on the part of persons or entities Card Number
listed above. It is understood that some recreational activities involve an ele-
ment of risk or danger of accidents, and knowing these risks, I hereby assume ________________________________
those risks. It is further understood and agreed that this waiver, release, and Exp. Date______________
assumption of risk is to be binding on my heirs and assigns. In the interest of I authorize the above charges.
the safety and well being of all participants we reserve the right to deny
service to any participant. By signing this release, I agree to the use of my Cardholder’s Name (Printed)
name and/or photo for City publicity. The city is not responsible for lost or _______________________________________
stolen items.
Signature_________________________________ Date__________________
Parental Consent: (To be completed if applicant is under 18 years of age): I give my consent for my son/daugh-
ter____________________________ to participate in the above activity and I execute the above liability release on his/her
behalf. I have read and understood the foregoing registration form, liability release form, and parental consent form, and agree
to all their terms and conditions.