Carbon County Recreation
             
 
Castleview Weight Loss Individual Registration:   $15.00   Quantity:   Item Subtotal:  
$0.00
Participant's First and Last Name [1]
Age [1]
T-Shrit Size [1]

Participant's First and Last Name

[2]
Age [2]
T-Shrit Size [2]

Participant's First and Last Name

[3]
Age [3]
T-Shrit Size [3]

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[4]
Age [4]
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[5]
Age [5]
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Participant's First and Last Name

[6]
Age [6]
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[7]
Age [7]
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[8]
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[9]
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Participant's First and Last Name

[10]
Age [10]
T-Shrit Size [10]
 
Castleview Weight Loss Family Registration:   $25.00   Select:   Item Subtotal:  
$0.00
(Family price does not include t-shirts)
Number of Family Members Participating:     Quantity:    
Participant's First and Last Name [1]
Age [1]

Participant's First and Last Name

[2]
Age [2]

Participant's First and Last Name

[3]
Age [3]

Participant's First and Last Name

[4]
Age [4]

Participant's First and Last Name

[5]
Age [5]

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[6]
Age [6]

Participant's First and Last Name

[7]
Age [7]

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[8]
Age [8]

Participant's First and Last Name

[9]
Age [9]

Participant's First and Last Name

[10]
Age [10]
 
Castleview Weight Loss T-Shirts:   $8.00   Quantity:   Item Subtotal:  
$0.00
T-Shirt Size [1]

T-Shirt Size

[2]

T-Shirt Size

[3]

T-Shirt Size

[4]

T-Shirt Size

[5]

T-Shirt Size

[6]

T-Shirt Size

[7]

T-Shirt Size

[8]

T-Shirt Size

[9]

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[10]
 
Donation
Donation for Frank Ori and Family:   $   Item Subtotal:  
$0.00
 
Total:
$0.00
Payer's Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone: Email:
Payment Information
Method of Payment:
Update name from Payer's Information
Name of Individual
on Checking Account:
Name of Individual
on Savings Account:
Name of Business
on Checking Account:
Bank Routing Number:
Bank Account Number:
Credit Card Number: (Type number or swipe with cursor in this empty field)
Expiration Date: /
Card ID (CVV2/CID) Number: What is the Card ID?
Cardholder Information (exactly as it appears on your statement)
  Update from Payer's Information
Cardholder's Name:
Billing ZIP/Postal Code:

Release of Liability/Consent Form:

The participants listed above are physically fit and otherwise able to participate in this program. I understand the program will be supervised and I further understand Carbon County Recreation and its employees will  not be held liable for any accidental injury incurred while the participants listed above are participating or while being transported to and from games.  I authorize emergency treatment for any accident or illness and consent to allow Carbon County Recreation and its volunteers to use their discretion in administering First Aid medical care to all participants listed above. 

Code of Conduct Agreement:

As a Parent/Guardian or Participant I agree to adhere to the Carbon County Recreation code of conduct guidelines that include demonstrating sportsmanlike conduct at all times. I agree to treat all volunteers, teammates, refs/officials and the recreational staff with respect and understand that vulgar or offensive language and poor sportsmanship directed at anyone involved will not be tolerated. I also agree to treat county property and equipment properly and may be held responsible for any damage or misuse of such property and or equipment.  If at any time I neglect to follow these guidelines I may be asked to leave the premises and participation may be suspended or terminated as deemed necessary by the Carbon County Recreation supervisory staff.

Parent/Guardian Agreement:

I hereby certify that my child/children are in good health and capable of participating in the sports programs selected above and has accident insurance and that Carbon County Recreation and all other participating agencies are not liable for any accident while participating.

I hereby authorize the directors of the Carbon County Recreation Department to act in my behalf in accordance with their best judgement in case on an emergency.

I understand the goal and objectives of the Carbon County Recreation Department, which are based on fun, fair play, skill development and teamwork.
Participant(s)
I have read and agree to the statements above.
 

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Carbon UT 800-764-0844 Price UT

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