Community Services
Printable Registration Form

Personal Information

First Name:

Last Name:

Street Address:

City:

Zip Code:

Business Phone:

Home Phone:

E-mail:

Class Information

Event #	Event Title	#	of Participants and Names	Fee	Total

Credit Card Information

Visa/MC/Discover#:

Exp. Date:
(Format: MMYY)

MEDICAL RELEASE FORM REQUIRED FOR ALL
“COLLEGE FOR KIDS” PROGRAMS

By my signature below, I hereby give permission for my child to participate in the “College for Kids” Program. In permitting the above named child to participate in the program, the undersigned hereby voluntarily releases, discharges, waives and relinquished any and all actions or causes of action for personal injury, bodily injury, property damage or wrongful death occurring to him/herself arising in any way whatsoever or however the same may occur and for whatever period said activities may continue. In the event of illness or injury, I do hereby consent to whatever medical and/or dental treatment are considered necessary in the best judgment of the attending medical staff, and/or Rancho Santiago Community College District staff. I also understand that Rancho Santiago Community College District does not provide health and medical insurance for participants. A responsible adult must accompany your child to the class site and must pick up your child at the site immediately following the completion of the class. Children who have not been picked up by responsible adult after 15 minutes, will be escorted to the office of District Safety.

Parent or Guardian:

Daytime Phone:

Emergency Contact/Relationship:

Emergency Phone:

Signature:

(Please type your name in the Signature box - form is considered incomplete without a signature)

DISCLAIMER STATEMENT: My typed name in the Signature box serves as my written signature, and is intended to be a legally binding acknowledgement that I have read and agree with the terms stipulated in the above medical release form.