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REGISTRATION FORM FOR ZHANG YONG TAO
TAI CHI CHUAN SEMINAR
Print This Form, Fill It Out Completely and
mail to:
City of Lakewood
P.O.Box 158
Lakewood, CA 90714
Or deliver to Lakewood City Hall at 5050 Clark Avenue in Lakewood
You may also FAX your registration to: (562) 866-0505
or you may e-mail your registration to: www.lakewoodcity.org
| Class # | Last Name, First Name of Participant | Age | Class Name | Day(s) | Time | Fee |
| #2521 | Yang Tai Chi Chuan Workshop/Seminar | Saturday | 8am to 5pm | |||
| #2522 | Yang Tai Chi Chuan Workshop/Seminar | Sunday | 8am to 5pm | |||
| Total | ||||||
Refunds are accepted if received before the second class meeting. There is a $5 administrative fee for refunds. I, the undersigned parent or guardian, do hereby agree to allow the individual(s) named herein to participate in the aforementioned activity(ies) and further agree to indemnify and hold harmless the City of Lakewood, its agents and employees from all harm, accident, personal injury or property damage which may be suffered in the aforementioned individual(s), arising out of, or in any way connected with participation in this activity. I understand that there will be pictures and video made from this event and do give my consent to use my image for publicity and resale.
Signature:
_____________________________________________ Date:
__________________
Payor: __________________ Method
of Payment : ___Check ___Credit Card ___Money Order ___Cash
Address:
___________________________________________ Day Phone:
_________________
City: _____________________________Zip:___ ______________Night
Phone:_________________________
Person to notify in case of emergency: ______________________ Emergency
Phone:__________________
____ Mastercard ____Visa
Card Number: __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __
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Expiration Date: _____________
Name as it appears on the card: ___________________________________________________
Signature: _____________________________________________________________________
