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Registration Form
Please Print Form, Fill Out Completely and return to:
City of Lakewood
P.O.Box 158
Lakewood, CA 90714
Class Information
Last Name First Name Age
Class Number Class Name Class Fee
Class Day(s) Class Time

Total Fee

Refunds are accepted if recieved before the second class meeting. There is a $5 administrative fee for refunds. I, the undersigned parent or guardian, do hereby agree to allow the individual(s) named herin to participate in the aforementioned activity(ies) and further agree to indemnify and hold harmless the city of Lakewood, its agents and employees from all harm, accident, personal injury or property damage which may be suffered in the aforementioned individual(s), arising out of, or in any way connected with participation in this activity.

Signature Date
Payor Method of Payment Check Credit Card Money Order Cash

Address
City Zip Driver Lic.
Day Phone Eve. Phone Emergency
Person to notify in case of emergency

Mastercard Visa ($25.00 minimum) Card Number
Name as it appears on the card
Signature

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