Last Name______________________________

First Name ________________________

Home Phone __________________

Day Phone ___________

Message Phone_____________

Address ________________________

City _________________

Zip__________

e-mail______________________________________________________________________

__________

__________

TOTAL FEE $__________

Check #__________ (Make payable to Spanaway Learning Center)
For and in consideration of permission to participate in the recreation activity, I, the undersigned participant (if over age 18) or parent or guardian (if participant is under 18) completely release and agree to indemnify and hold Bethel School District and its employees, its hired or contracted instructors and any other person, volunteers or organizations affiliated with Bethel School District in connection with this recreation activity harmless from and against any and all liability for any injury or damage from negligence or otherwise which may be suffered by the participant arising out of or in any way connected with this recreation activity. I realize that recreation activities have an inherent risk of physical injury. If the participant has any physical ailments or conditions that might affect his/her health by participating in the activity, I have consulted a physician or other medical authority and received permission to participate.

Authorized Signature ___________________________ Date __________________

OFFICE USE ONLY:

Paid $ Cash_____

Check _____

Receipt #________

Date_______