Enrollment Form #2


 

______    Year

______   Sumr

______      Fall

  ______ Spring

______  Other

 

DEPARTMENT OF PARKS AND RECREATION

CITY AND COUNTY OF HONOLULU

PROGRAM REGISTRATION FORM                   MILILANI DISTRICT PARK          

                                                                                     Playground or Area

Check one: ________ Tiny Tot Program

                   ________  Children Program

                   ________  Teenage Program

                   ________  Adult Program

                   ________  Senior Citizen Program

                                                                                                 Home Phone:  _______________________________

Name:  ________________________________________    Business Phone:  (if applicable):  _______________

Home Address:  ________________________________  City:  ________________________Zip:  ____________

Age:  __________  Date of Birth:  __________________  Male:  _______________  Female:  ________________

School (if applicable):  ___________________________  Grade (if applicable):  __________________________

Physical limitations, if any:  ____________________________   Allergy:  _______________________________

Family Physician:  _____________________________________  Physician’s Phone:  _____________________

Physician’s Address:  _____________________________________  City:  _______________  Zip:  __________

Health Plan (if applicable):  _____________________________________________________________________

In case of emergency, please contact the following person(s):

Mother’s Name & Bus. Phone:  __________________________________________________________________

Father’s Name  & Bus. Phone:  __________________________________________________________________

Other:  _________________________________________  ___________________________  _________________

                                     Name                                                              Relationship                                Phone

                           

                                       REGISTERED ACTIVITIES                                                                              FEE

  1. _______________________________________________________________         _______________________
  2. _______________________________________________________________         _______________________
  3. _______________________________________________________________         _______________________

I hereby authorize the City or any of its employees to refer said applicant, if injured or ill, to my family physician when I or my spouse cannot be reached.  If no family physician is designated, the City or any of its employees is authorized to select any physician when deemed necessary.  I, the undersigned, hereby waive all responsibility from the City and County of Honolulu, Department of Parks and Recreation, and any employee or volunteer acting with the permission of the Department, from all liabilities arising from property damage and bodily injury which may be sustained by participating in the above activity.*

______________________________________                           __________________________________________

                                       Date                                                                         Signature/Parent or Guardian

 

*  NOTICE:  City and County policy requires that all accidents resulting in property damage or personnel injury, or both, be reported promptly.  Please be advised that your personal medical and health insurance should be relied upon to cover all medical costs incurred because of accidental injury.  Any claim against the City and County seeking reimbursement for all or part of such costs will be evaluated on a case-by-case basis by the Corporation Counsel to determine if there is any liability thereof.