Piedmont Recreation Department
REGISTRATION FORM 358 HILLSIDE AVENUE • PIEDMONT, CA 94611 • 510.420.3070 • PRD@PIEDMONT.CA.GOV
Instructions for Registration Form:
Cancellations and Refunds
• Complete Registration Form. • Multiple participants can register per form. • Payment and signature are required to process form. • Once your registration is processed, a confirmation will be emailed to you. • You will not be charged for any wait listed classes.
• Refunds, credits, or transfers will only be processed if the Recreation Dept. is contacted at least FIVE business days (TEN days in summer) prior to course start date. Cancellations will not be accepted after this time, except for courses cancelled by PRD. • Credits and/or refunds will not be issued for non-attendance. • Credits within the cancellation period will be applied to your account for future use. Refunds are charged a 10% processing fee.
Participant's Name
Grade in Fall
Date of Birth
Gender Course Number
Course Name
Method of Payment
Fee
Total Fee
PRD strongly encourages online registration through ACTIVE Net: activenet.active.com/piedmontrecreation For your convenience, e/mail, or walk-in registration will continue to be available. However, in accordance with new regulations, credit card information may not be written in full on our Registration Form. Please choose from the following when using paper registration: Check
Cash
Credit card - stored number (ending in _____________ ) on ACTIVE Net account
If you or your child has an allergy, medical alert, or special need, please check here and notify Piedmont Recreation Department. If your child has a medical alert, please specify:
Adult Name First
Last
Address
City
Street
Phone Day
Mobile
State
Emergency Contact and Phone
Zip
Relationship
Consent: I hereby absolve the City of Piedmont, its employees, and officers from all liability that may arise as the result of my participation in the above mentioned activities, and in the event that the above named participant is a minor, I hereby give my permission for his/her participation as indicated and in so doing absolve the City of Piedmont, Piedmont Unified School District, its employees, and officers from such liability. I agree to and understand that cancellation or transfer requests must be made five working days (ten days in summer) prior to the first course meeting unless courses are canceled by the Recreation Department. There is a 10% fee charged to process refunds. Exceptions cannot be made to this policy. I also understand that the City of Piedmont Recreation Department occasionally takes photos of department programs and that these photos may include me or my child. I hereby authorize use of these photos for promotional or marketing purposes at the discretion of the Piedmont Recreation Department. I have read the registration instructions and policies and agree to abide by them. Signature Date
62 www.piedmont.ca.gov • 510.420.3070