Leisure Ledger January - April 2018

Account and Program Registration Form Main Contact  Raleigh Resident  Non-resident Add $15 to course. Non-resident fees do not apply to Specialized Recreation Programs or courses less than $15. Last Name _____________________________________ First Name ___________________________ DOB _____ / _____ / ____  Male  Female Mailing Address __________________________________________________________ City _____________________ State _______ Zip ____________ Home Phone ___________________ Work Phone ___________________ Cell Phone ___________________ *Email ___________________________ Emergency Contact __________________________________________________________________ Phone ____________________________________ Pictures or video may be taken of participant for use in program publicity.  Please check, if you do not approve Registration Receipt: (for mail-in) I would like my receipt (please check one)  emailed (valid email address required)  printed/mailed * By providing my email address I agree to receive email communication from Raleigh Parks, Recreation and Cultural Resources. The City of Raleigh Parks, Recreation and Cultural Resources Department welcomes the participation of all individuals, including those with disabilities or special needs. We are committed to compliance with the ADA and will provide reasonable accommodations to facilitate participation in our programs. To ensure that reasonable accommodations are in place, program registration or accommodation request should be received at least two weeks prior to the start date of the program. For more information please contact Inclusion Services 919.996.2147 Participant #1 Information Participant #1 Name _________________________________________________________________ DOB _____ / _____ / ____  Male  Female Parent/Guardian Last Name If participant is under 18 __________________________________ Parent’s First Name ___________________________ I want Parks, Recreation and Cultural Resources to know about these medical conditions for the participant: _________________________________________________ I want Parks, Recreation and Cultural Resources to know about these disabilities for the participant: __________________________________________________________ I request ADA accommodation for the disability/medical condition listed.  Yes  No Course Barcode Program Name Location Date Time Fee ___________________ ____________________________________ __________________________ _____________ ________ $_______ ___________________ ____________________________________ __________________________ _____________ ________ $_______ Participant #2 Information Participant #2 Name _________________________________________________________________ DOB _____ / _____ / ____  Male  Female Parent/Guardian Last Name If participant is under 18 __________________________________ Parent’s First Name ___________________________ I want Parks, Recreation and Cultural Resources to know about these medical conditions for the participant: _________________________________________________ I want Parks, Recreation and Cultural Resources to know about these disabilities for the participant: __________________________________________________________ I request ADA accommodation for the disability/medical condition listed.  Yes  No Course Barcode Program Name Location Date Time Fee ___________________ ____________________________________ __________________________ _____________ ________ $_______ ___________________ ____________________________________ __________________________ _____________ ________ $_______ Account Information  Create a New Account  Update my Account  Please send me My Family PIN and Client Barcode Registration Information Payment is required at the time of registration. Please use this form for registration, and mail to the facility where the program is held. Non-City of Raleigh Resident Fee ($15/course) $______________ I would like to make a donation to support a child’s participation in Raleigh Parks, Recreation and Cultural Resources Programs (specify amount) $_______________ TOTAL AMOUNT DUE $_______________ Remember you can also register online with RecLink at parks.raleighnc.gov

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