Tregnan Golf Academy - City of Los Angeles Department of ...

Tregnan Golf Academy - Summer 2014Open Enrollment and Recreation Center ApplicationFirst Name ___________________________ Last Name_______________________Address______________________________ City _______________ Zip ________Home Phone ( ) ______________________ Emergency Phone ( ) _____________Mother/Guardian _______________________ Father/Guardian __________________Male ( ) Female ( ) Age _____ Birth Date __________________Email Address _________________________Returning Applicant ( ) New Applicant ( ) No Experience ___ A Little Experience __The following information is for statistical purposes only!Asian/Pacific Islander __ Black __ Hispanic __ White __ Other __Check one box next to the Recreation Center from which you need transportation or circle theOpen Enrollment Class ID if you will be transporting your child.Monday4pmMonday5:45pmTuesday4pmTuesday5:45pmWednesday4pmWednesday5:45pmThursday4pmThursday5:45pm[][]Shatto[]Pan Pacific[][]Reseda[][]Studio City[]Glassell[ ] Carlin G. Smith[]Silverlake[]Ritchie Vallens[][ }Hollywood/Yucca[][]Pointsettia[]E agle Rock[ ] No. Weddington[]Bellevue[]Sunland[][]Woodland Hills[][][]CypressMondayOpen EnrollmentClass ID 1031MondayOpen EnrollmentClass ID 1032TuesdayOpen EnrollmentClass ID 1033TuesdayOpen EnrollmentClass ID 1034WednesdayOpen EnrollmentClass ID 1035WednesdayOpen EnrollmentClass ID 1036ThursdayOpen EnrollmentClass ID 1037hursdayOpen EnrollmentClass ID 1038OpenEnrollmentSaturday8:30amClass ID 103910:30amClass ID 104012:30pmClass ID 10412:30pmClass ID 1042PARENT CONSENT FORMI, the undersigned, give permission for my child, whose name appears above, to participate in the Tregnan golf program. I understandthe nature of sports activities and the minor’s experience and capabilities and believe the minor to be qualified, in good health, andin proper physical condition to participate in such activity. I give permission for my child to be transported by City vehicles as a partof his or her participation in the Tregnan Golf Academy program. I agree to relieve the City of Los Angeles Department ofRecreation and Parks, its officer agents and employees from any liability in connection with any injury to my child in connection withmy child’s participation.I, the undersigned parent of _________________________________________, a minor, do hereby authorize City of LosAngeles, Tregnan Golf Academy as agents for the under-signed to consent to X-ray examination, anesthetic, medical or surgicaldiagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specializedsupervision of any physician licensed under the provisions of the Medical Practice Act on the staff of a licensed hospital, whethersuch diagnosis or treatment is rendered at the office of said physician or a said hospital. It is understood that this authorization isgiven in advance of any such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his bestjudgement may deem advisable. This authorization shall remain effective for the duration of the program, unless revoked sooner inwriting and delivered to the Academy’s Executive Director.I understand that the program carries no insurance. I understand that I will be responsible for equipment provided by the programand that all equipment remains the property of the junior golf program.I agree to allow the use of any photographs and or images of my child participating in any sponsored event for any promotional and/or marketing materials.Persons authorized to pick my child up are: I give my permission for my child to sign him/herself out? Yes NoName _________________________ Address _____________________________________ Phone ________________Name _________________________ Address _____________________________________ Phone ________________Signature of Parent or Legal Guardian ____________________________________ Date _______________