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2. Today's Date*
   Today's Date
3. * Required Field
5. Participant Name*
6. Middle Name
7. Last Name*
9. Current Address: Street*
10. City*
11. State*
12. Zip*
14. Phone Number*
15. Work Phone
16. Email Address*
18. Gender*

    1. Male
    2. Female
    3. Prefer Not to Say
20. Allergies/Health Problems, past or present*
22. Emergency Contact Name*
23. Emergency Contact Number*
25. Activity*
    -- Select One --Itty Itty Bunnies (18mos - 3): 6-6:30pm/Senior Center - $100.00 FeeBizzy Bunnies (3-4 years old); 6:30-7pm/Senior Center - $100.00 FeeHappy Hoppers (5-7 years old); 7-7:30pm/Senior Center - $100.00 Fee
29. Waiver, Release of Liability & Indemnity Agreement

    In consideration of myself acceptance the registration in the above program(s) do I hereby, for myself or  my heirs, executors and administrators, waive release and forever discharge any and all rights and claims for damages which I  may have or which hereafter accrue to me against all municipalities special districts, and properties through which the program(s) will be held or its respective officers, instructors, administrators, successors, and/or assigns for any and all damages which may be sustained or suffered by me  in connection with my said participation in the above program(s). I further represent that I'm in good physical condition and have no disability or ailment that will prevent me from engaging in the activity for which I am registered.

33. Our Photo Policy

    Enrollment in Parks and Recreation Department sponsored programs authorize Romulus Parks and Recreation, its departments, employees and contractors to take your photograph for use in future brochures, flyers, documents, displays, and other publications, website and on social networking websites. Parks and Recreation will not sell, use or authorize others to use such photographs for commercial purposes

34. Please Initial*
36. Electronic Signature Agreement*

    I, the undersigned parent or legal guardian of the child shown below, have read the above Waiver, Release and Indemnity Agreement and agree to its terms on behalf of my child and myself.  I understand that by signing below, I am giving up substantial rights on behalf of my child and myself.

    1. I agree.
38. Electronic Signature of Participant*
39. Date*
    Date
43. Disclaimer

    No class confirmations are mailed out. You will only be notified if your class is cancelled. Proper fees must be enclosed for valid registration. No class or program openings will be held or saved for persons registering without payment. Registrations are taken on a first come, first serve basis. Mail-in registrations must be received at least one (1) week prior to the beginning of class. Check or money order is accepted. Nominal fee will be charged for credit card use. Checks can be made out to the City of Romulus.

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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field