REGISTRATION FORM PLEASE PRINT & FILL OUT COMPLETELY PRIMARY GUARDIAN PLEASE CHECK IF Is this your first time participating in our program(s)? ___ Yes ___ No FIRST ADDRESS Household # CITY PRIMARY PHONE EMERGENCY PHONE ( REG. # ( ) ) - PLEASE LIST CLASSES IN ORDER OF PREFERENCE PARTICIPANT NAME LAST FIRST - STATE SECONDARY PHONE EMERGENCY CONTACT EMAIL ADDRESS MO BIRTHDATE DAY YEAR SEX ACTIVITY NAME FEES ( ) ZIP CODE - INITIALS RECEIPT # ADDRESS BELOW IS NEW PREVIOUS STREET Do you work in Kettering? ___ Yes ___ No If yes, where? _________________________ LAST MI OFFICE USE ONLY DATE The City of Kettering invites people with disabilities to enjoy our programs, services, parks and facilities. Participant needs a modification because of a disability. _____ Yes _____ No WAIVER FOR PARTICIPANT AND/BY PARENT I, for myself and my child(ren), agree to assume all risks, including, but not limited to, risk of physical injuries, death, loss of services or consortium, loss or damage to property, or any other loss or damage I or my child(ren) may sustain as a result of participating in any and all activities connected with or associated with this program(s). In consideration of the City of Kettering allowing my child or my children to participate in this program, and with the intent to be legally bound, I hereby, for myself, for my child, all heirs, executors, administrators, and assigns, do hereby forever: release, waive, and relinquish all claims I or my child have or may have as a result of participating in this program; promise not to sue the City of Kettering or its officers, employees and agents; and agree to indemnify and hold harmless and defend the City of Kettering and its officers, employees and agents, from any and all liabilities, claims, demands, actions or causes of action resulting from, whether directly or indirectly, my or my child’s participation in this program; and grant and give the City of Kettering the right to use my or my child’s photograph or image, with or without my or my child’s name, both individually and in conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity and promotion. By signing below, I certify that I have read and agree to be bound by these conditions and that all information contained herein is true and that I am giving up legal rights. PATRON SIGNATURE RESIDENT STATUS The Resident Card has been designed to identify resident and non-resident users. To receive resident rates when attending drop-in and/or daily admission activities or registering for a program, Kettering residents or a person working in Kettering must produce identification. The following sources of I.D. are accepted as proof of residency. Living in Kettering: • A valid Ohio driver’s license with Kettering address. • Current utility bill with Kettering address, accompanied by a valid photo I.D. Working in Kettering: • Pay stub that includes City of Kettering income tax withholding. Youth (defined as persons 17 or younger): • School I.D.s are accepted for youth 17 and under. The Resident Card will provide quick identification at Parks, Recreation and Cultural Arts facilities or programs and identify them to be entitled to the Kettering resident fee. The free Resident Card can be obtained at any information desk. PAYMENT METHODS The City will accept cash, personal checks, credit cards (Visa, MasterCard and Discover) and money orders for the payment of fees. The City can only accept debit cards that can be processed as credit cards (non-pin). The City will charge a $25 service fee for all checks not honored for any reason by the bank. Checks should be made payable to: City of Kettering. CONFIRMATION For Mail-in and Drop-off Registrations Once your registration is processed, a confirmation will be emailed to you including your class enrollment status. If we were unable to place you in a class, your payment will be returned to you. LATE REGISTRATION Late registrations will be accepted prior to the second class meeting. After the second class meeting, no registrations will be accepted. Individuals registering late will be required to pay the total class fee. REFUND POLICY OUR COMMITMENT TO YOU We strive for positive experiences and excellence in everything we do. All refunds will be made according to the following guidelines: For more information, call 937.296.2587. • If you have attended one of our classes or purchased a pass and are dissatisfied, call us. We will offer a prorated refund. • If you were unable to attend a set of classes, we will try to transfer you to another section. Otherwise, we will offer a 50% refund of the class price. • Special consideration will be given for life altering situations. • Refund requests must be made within 30 days of a registered program’s end date. Refunds will be issued via the following method: If the original transaction was paid using cash, check or household credit, the refund will be issued via City check. If the original transaction was paid by credit or debit card, the refund will be issued back to the card used for payment. There will be no cash refunds. This policy does not apply to facility rentals. See your rental contract for cancellation details. NOTICE TO PARTICIPANTS Participants must recognize that all classes/activities of a physical nature involve some risk and by registering for a class/activity of this nature, there is an assumption of risk by the participant. The City of Kettering Parks, Recreation and Cultural Arts Department is dedicated to providing safe facilities and equipment for all participants, as well as qualified staff. Every effort is made to ensure the safety of the participants and to provide them with first-class recreational activities, facilities and parks. In the event of a serious accident or illness, it is the policy of the City of Kettering to: • Contact the Kettering Fire Department Paramedics to perform first aid and, when necessary, recommend transport of the victim to a hospital; and • Reach the parent or guardian as soon as the situation allows. ADA MODIFICATIONS The City of Kettering understands the Americans with Disabilities Act requirements. We invite participation by people with disabilities, alongside people without disabilities, in our programs, sites and facilities. The Modification Request Form is available at all Kettering Parks, Recreation and Cultural Arts front desks as well as online at www.playkettering.org/ modification. Please fill out and return to the front desk or email completed form to [email protected] after you've enrolled. We want you to begin the program on time. The sooner we know about your needs and how we can support you in our programs, the more likely participation will not be delayed. However, if delays in communication occur, we will delay the start of program participation. Please register early and submit this request form early. playkettering.org 81 Make check or money order payable to the City of Kettering and mail to CLASS REGISTRATION, Kettering Parks, Recreation and Cultural Arts Department, 2900 Glengarry Drive, Kettering, Ohio 45420. FORM OF PAYMENT 1 CASH 2 CHECK 3 MONEY ORDER 4 CREDIT CARD TOTAL FEES: TOTAL AMOUNT ENCLOSED: $ $ TO PAY BY CREDIT CARD, PLEASE CALL OR VISIT ANY INFORMATION DESK OR VISIT WWW.PLAYKETTERING.ORG REGISTRATION FORM
