Program Registration Form

2. Please use cheque or money order for mail-in or drop-off registrations. Make cheques payable to the City of Beaumont. Registration and a signed waiver required for all programs.

4. Surname

5. Parent / Guardian Name

7. Address

8. Postal Code

10. Home Phone Number

11. Work / Cell Phone Number

13. Email

15. Where did you hear about the program?

    1. Website
    2. Brochure
    3. Newspaper

    1. Friend
    2. Other

16. Other

20. Participant Name

21. Birth Date
    Birth Date

22. Male / Female

24. Program

25. Date / Time
    Date / Time

    Date / Time

26. Fee

30. Participant Name

31. Birth Date
    Birth Date

32. Male / Female

34. Program

35. Date / Time
    Date / Time

    Date / Time

36. Fee

40. Participant Name

41. Birth Date
    Birth Date

42. Male / Female

44. Program

45. Date / Time
    Date / Time

    Date / Time

46. Fee

50. Participant Name

51. Birth Date
    Birth Date

    Birth Date

52. Male / Female

54. Program

55. Date / Time
    Date / Time

    Date / Time

56. Fee

60. Participant Name

61. Birth Date
    Birth Date

    Birth Date

62. Male / Female

64. Program

65. Date / Time
    Date / Time

    Date / Time

66. Fee

70. Allergies

72. Medical Considerations

74. Gymnastics badge last received:

76. If the course if full, I would like to:

    1. Remain on the Waiting List

    1. Have a Refund Mailed

    1. Register in an Alternative Course

80. Waiver for Activities
    The following Waiver for Activities must be completed before attending any program.

    The following Waiver for Activities must be completed before attending any program.

82. I give permission for myself/my child(ren) to participate in the above noted program. I understand the nature of the activity, the limited supervision provided and that there are inherent risks associated with this activity and that I or my child(ren) could sustain personal injury through participation in this activity and I am hereby accepting to take that risk on behalf of myself or my child(ren). I hereby agree to save harmless and indemnify the City of Beaumont, its organizers, agents or employees against claims, expenses and demands in respect to injury or death arising out of myself or my child(ren) taking part in this activity but limited to taking part in this activity.

84. Child's Name(s)

86. Signature of Participant / Parent or Guardian (if under 18)

88. Witness

89. Date
    Date

91. The personal information requested on this form is being collected under the authority of the City of Beaumont Bylaw 382 and Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The information collected will be used as for the purpose of setting up utility billing.
    
    If you have any questions about the collection or use of your personal information, contact the City of Beaumont’s FOIP Coordinator at:
    City of Beaumont's FOIP Coordinator
    5600-49th Street
    Beaumont, AB T4X 1A1
    Phone: 780-929-8782

Leave This Blank:


93. 1. Receive an email copy of this form.
94. Email address

    This field is not part of the form submission.

95. Submit

* indicates a required field