Zumba in the Park

Zumba Class in the park will be offered on July 24th and August 7th at 7:00pm at the Prairie Lily Field - the Soccer Field. Register for either or both dates!

PARTICIPANT INFORMATION

Participant Name *

Physical Address *

Age (must be 18+) *

Phone Number *

Email Address *

Important Information ie; allergies, medications, disability, pronouns, etc:

Dates to attend (select either or both!) * Friday July 24th at 7:00pm
Friday August 7th at 7:00pm

EMERGENCY CONTACT INFORMATION

Emergency Contact Name *

Emergency Contact 1 - Phone Number *

Emergency Contact 1 - Relationship *

WAIVERS

Waiver of Liability

I agree to release, indemnify and save harmless the Town of Pilot Butte, and its elected officials, officers, employees, agents, representatives, volunteers, and other participants from and against all claims, proceedings and/or actions in respect of any costs, losses, damage or injury arising by reason of my or the dependent registrants’ participation in any activities offered by the Town of Pilot Butte, or by reason of the provision of medical care by the Town to me or the dependent registrants.

Waiver of Liability Agreement * I have read and understand the Waiver of Liability.

Town of Pilot Butte Image Release

I hereby grant permission to be photographed during the program for memorabilia and/or promotional material. I further acknowledge that the Town of Pilot Butte are the owners of all publication materials, and that photos may be used in any exhibitions, public displays, publications, commercial art, and advertising purposes including television without limit or reservation.

Town of Pilot Butte Image Release Agreement * I agree
I do not agree to these terms and do not consent to having my photo taken

* - denotes required field