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2. PART 1 - Personal information
4. Family Contact
   First & Last Name
6. Address
8. City
9. Zip Code
11. Home Phone
12. Work Phone
14. Cell Phone
15. Email Address (To receive future updates about City Activities.)
17. Emergency Contact
    Name
18. Relationship
20. Emergency Contact Phone
22. PART 2 - Complete information for each participants
24. Participant 1 Name
25. Sex
27. Birthday
28. Title of Activity
29. Fee Amount
31. Participant 2 Name
32. Sex
34. Birthday
35. Title of Acitivity
36. Fee Amount
38. Participant 3 Name
39. Sex
41. Birthday
42. Title of Activity
43. Fee Amount
45. Participant 4 Name
46. Sex
48. Birthday
49. Title of Activity
50. Fee Amount
52. Participant 5 Name
53. Sex
55. Birthday
56. Title of Activity
57. Fee Amount
59. Participant 6 Name
60. Sex
62. Birthday
63. Title of Activity
64. Fee Amount
66. Total Fee Amount
68. Please describe any accommodation needed for your enjoyment of this program:
70. PART 3 - Signature
72. Waiver & Release of All Claims - Must be signed or registration cannot be processed.
    I fully understand that my participation in the above event/class exposes me to the risk of personal injury, death or property damage. I hereby acknowledge that I am voluntarily participating in the event/class and agree to assume any such risk. I hereby release, discharge, and agree not to sue the City of Quincy for any injury, death or damage to or loss of personal property arising out of, or in connection with, my participation in the event/class from whatever cause, including the active or passive negligence of the City of Quincy or any other participant in the event/class. In consideration for being permitted to participate in the event/class, I hereby agree, for myself, my heirs, administrators, executors and assigns, that I shall indemnify and hold harmless the City of Quincy from any and all claims, demands, actions or suits arising out of or in connection with my participation in the event/class. The applicant/organization assumes all risks normally associated with the activity. The applicant/organization agrees to hold the City of Quincy, their employees, agents, representatives, and volunteers harmless from any and all liability, actions, and causes of action, debts, claims or demands of any kind and nature whatsoever, which may result from such risks. The terms hereof shall serve as a release and assumption of risk by all parties engaged in the sponsorship and in the participation in the activity, as certified by the undersigned. I also grant permission to any and all of the foregoing the free use of my name, voice, and/or likeness in any broadcast, telecast, advertising and/or promotion related to this event or future Quincy Recreation Department events. It is the applicant’s responsibility to make sure each member using the facility is aware of the Hold Harmless Agreement.
74. I have read and fully understand the program details and waiver and release of all claims.

    1. Yes
76. PART 4 - How did you hear about us?

    1. Facebook
    2. Newspaper
    3. Website
    4. Friends
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field