Registration Form

390 N. 23rd St. Billings, MT 59101 406-657-8371 www.BillingsParks.org

Head of Household: First Name: ______________________________________ Last Name: _______________________________________ Address: ___________________________________________________________________________________________ City: __________________________________ State: _____________________________ Zip: ___________________ Phone 1: _____________________________ Type: ________________ Phone 2: _____________________________ Type: ________________ Email: _________________________________________________________________________ Gender: ________________________________ Emergency Contact Name: ________________________________ Contact # :_________________________ Relation: _________________

Participant 1: Last Name: ________________________________ First Name: ________________________________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Medical Alert Information: __________________________________________________________________

Participant 2: Last Name: ________________________________ First Name: ________________________________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Medical Alert Information: __________________________________________________________________ M F

Date of Birth:

M F

Date of Birth:

Participant 3: Last Name: ________________________________ First Name: ________________________________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Activity #: ___________________ Activity Name: _____________________________ Activity Cost: $____________ Medical Alert Information: __________________________________________________________________ M F

Date of Birth:

Check # :_____________________________ Payable to City of Billings

Cash Amount: $_______________________ Name on Card: ________________________________ Card Number: _________________________________ Expiration Date: _______________ DiscoverVisa Mastercard Only complete card info if your sending this form in:

Refund Policy: For any cancellation please fill out our Refund Form found online or can be picked up at the main office. All refund requests must be submitted during business hours using the refund request form. All refunds will be processed the next business day after receiving the refund request form. Any refund 7 days or less that is before the rental start-date will not receive a refund; 8 days before the rental start-date can receive a 50% credit to the household account in lieu of a refund; 9-14 days before the rental start-date, can receive a 75% credit to the household account, or 50% refund. Any refund 15 days or greater before the rental start-date can receive a 100% credit to the household account, or a full refund minus a 5% processing fee. Informed Consent/Participant Release: In consideration of your accepting mine or my child’s entry, I hereby for myself my child’s my heirs, my executors and administrators, waive and release any and all rights and claims for damages I or my child may have against the City of Billings and/or School District #2 and its representatives, successors and assigns for any and all injuries suffered by myself or my child at any activity sponsored or coordinated by either of these groups. I hereby release from liability and waive and all claims against any person who, on behalf of the City, is involved in the transportation of participant in connection with sponsored activity. I hereby consent to emergency medical treatment of participant to assure prompt treatment and prevention of undue delay, and I understand that such treatment may be provided by either a licensed physician or trained emergency care technician. I agree that the City may use, reproduce, disclose, and distribute the participant’s name and o/or likeness for the purpose of marketing and advertising. I acknowledge that I have read, fully understand and accept the above provisions and I recognize that the City is relying on such acceptance in permitting a participant to engage in the City’s activities.

I have read and understand the above regulations:

__________________________________________________________________________________ Date:__________________________________