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