Mail Forms to: 3291 Truxel Road, #26K, Sacramento, CA 95833
Attention: Phil, Access Leisure
Make Checks Payable To: City of Sacramento
Forms
[ ] Water Aerobics
Tuesday, July 6 [ ]; July 13 [ ]; July 20 [ ]; July 27 [ ];
- Bring Money Day of Events
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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[ ] Water Aerobics
TUE, AUG 3 [ ]; 10 [ ]; 17 [ ]; BRING $$ TO EVENT
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only # 68979: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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[ ] 68980-River Cats Vs Tacoma Rainiers, Wed., July 28, $33.00
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only # 68980: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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68981- RIVERCATS VS COLORADO SKY SOX, WED, AUG 25 — COST $33.00
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only # 68981: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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69174-Summer Daze Dance, Sat, August 21 - $8.00 (9.00 @ the door)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 69174: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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69630 - Paper Bowling Tournament League, Weds, July 28
$5.00 Per Week (Includes 2 Games And Shoes)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only:
July 28 - 69630
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Paper Bowling Tournament League, Weds, Aug 4 (69631) & Aug 11 (69632)
$5.00 Per Week (Includes 2 Games And Shoes)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only:
August 4- 69631 / August 11 - 69632
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68881-Lunch & Cinema, Sat, July 31st, Downtown Plaza Cost $8.00
(This Fee Must Be Mailed)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 68881: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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68882 - Lunch & Cinema, Sat. Aug 14, Downtown Plaza, Mail $8.00 (this fee must be mailed)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 68882 : Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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[ ] 68874 - Evening Social, mon, Aug 9, Mail $8.00 ($9.00 at the door)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 68874: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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68884-Crafts Day, Sat., July 24, Cost $12.00
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 68884: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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68877-Video Pizza Night, Mon, July 26, Cost $8.00 ($9.00 @ Door)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 68877: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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68878 Video/Pizza Night, Mon, Aug 2 - COST IS $8.00 ($9.00 at the door)
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 68878: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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69173 Lunchin’ Ol’ Sac & Railroad Museum, Mon, Aug 7, Mail $25.00
NAME _____________________________________ M[ ] F[ ] AGE _______
ADDRESS______________________CITY _____________ ZIP__________
PHONE#________________________ EMERGENCY#______________________
SPECIAL INFO_____________________________________________
Liability Release: I agree to hold the City of Sacramento, their directors, employees and committeemen harmless of any nature whatsoever for accident or injury to participants/myself arising out of or in any way connected with participation in city programs. I agree to give my consent to any medical treatment deemed necessary by a doctor.
SIGNATURE____________________________________ DATE___________
Office Use Only 669173: Amt Pd:$ __________ Amt Due:___________
Ck or MO#:_________Cash __ CC__ Rcpt #:_______Date: ___________
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