Credit Card Num

ber:

Expiration Date:

Card Holder Print N

ame:___________________________________

Payment A

mount $_________ A

uthorized Signature:___________________________________________

By registering or participating, the registrant understands that individual accident insurance is not provided for M

SCR programs and agrees to adhere to program

rules. I do hereby, for myself, m

y heirs, executors, and adm

inistrators, waive, release, and forever discharge any and all rights and claims for dam

ages that I m

ay have or that may hereafter accrue to m

e arising out of or, in any way connected with my participation

in MSCR Program

. Photos may be taken during program

for educational and marketing purposes. I have

read and agree to follow the registration and refund policies.

Sig

natu

re:

________________________________________________________________

MSCR Registration Form

Madison School &

Comm

unity Recreation Offi ce: M

SCR 3802 Regent St., Madison, W

I 53705 Phone: 608-204-3000 Fax: 608-204-0557

1. American Indian or

Alaskan Native

2. Asian3. Black or African Am

erican

4. Native Haw

aiian or O

ther Pacifi c Islander5. Hispanic 6. W

hite 7. M

ultiracial

Fee Total $ ____________

Donation $ ____________

Tota

l $____________

T-Shirt Size (if applicable to program)

N

ame:__________________________ Size:______

N

ame:__________________________ Size:______

Payment: (check all that apply) ____ Cash ____ Check #_________ (Payable to M

SCR)

__ I am applying for fee assistance. Please see reverse page. ____ Credit Card: M

asterCard or Visa Only

Last Nam

eFirst N

ame

Preferred PhoneA

lternate PhoneA

re you an MM

SD resident? (C

heck one)___Yes ___ N

o, Non M

MSD

residents pay 50 %

more. See page 48.

Street Address

Apt #

City

StateZip code

Email (Required for registration confirm

ation OR send a stam

ped, self-addressed envelope)D

o you require accomm

odations to particapte in an activity?___Yes ____ N

o Explain:

Please note disability or health concern (if any):

Head of H

ousehold/Parent/Guardian:

Para ayuda en español, marque el 204-3057

Para ayuda en español, marque el 204-3057.

Race: *Please indicate above using corresponding number: (O

ptional)Youth sizes

XSSMLXL

Liability Waiver - Signature Required for Participation

Participant’s Full Nam

eG

enderD

ate of Birth m

/d/y

Grade

2013-2014Race(below)

Choice

Program Title

LocationStart D

ateStart Tim

eC

ourse #Fee

1st

Alternate,

if any

1st

Alternate,

if any

1st

Alternate,

if any

1st

Alternate,

if any

/

IDs are required for classes at W

arner Park Comm

unity Recreation Center. Go to w

ww

.mscr.org for m

ore information.