Form Center

2. 
4. Teen Tech Center Registration Form
   Thank you for registering for the Teen Tech Center located at 4500 Spring Ave, Dallas, TX 75210. Please complete the following information.
8. Parent / Guardian Information
10. Name*
11. Contact Phone Number*
13. Email Address*
14. Driver's License / State ID Number*
16. Street Number
17. Street Name
18. Street Type
19. Apt #
21. City
22. State
23. Zip
27. Participant / Teen Information
29. Teen's First Name*
30. Teen's Last Name*
31. Ethnicity:
33. Date of Birth*
34. Age:*
35. School:
36. Grade:
38. Does your teen have a valid Recreation Card? *

    If your child does not have a valid recreation card, you will need to purchase one on the first day of camp. The card is $5 for one year and is valid at all 42 Dallas Recreation Centers.

    1. No
    2. Yes
40. If your child has a valid recreation card, what is the recreation number?
    (located on the back of the recreation card under the bar code)
44. Emergency Contact Information
46. Name*
47. Relationship to Participant*
49. Phone Number*
50. Alt Phone Number
52. Name
53. Relationship to Participant
55. Phone Number
56. Alt. Phone Number
60. Indemnity Clause*

    I agree to indemnify and hold harmless the CITY from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, which may occur to myself, my child(ren), other participants, and third-persons as a result of my/my child(ren)’s participation in the activity, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of the CITY.

    1. I agree
    2. I do not agree
62. Media Authorization Release*

    (PHOTOGRAPHS/VIDEO/AUDIO). I expressly give and grant to the CITY the unqualified right, privilege, and permission to reproduce, publish, and circulate in every manner or form (including radio, television, newspapers, magazines, and the internet) video tapes, films, photographs, transparencies, and other images and likenesses of me, my child(ren), family, and/or property and audio recordings of my and their voices (collectively referred to as “video and audio recordings”) , and I hereby grant, assign and transfer to the CITY all rights and interest therein at no charge. I specifically authorize and empower the CITY to cause any such video and audio recordings, to be copyrighted or in any other manner to be legally registered in the name of the CITY. I, for myself, my family, my child(ren), my heirs, executors, administrators and assigns, hereby remise, release, and discharge the CITY from any and all claims of any kind due to the use of such video and audio recordings, including all claims for damages or injunctive relief for libel, slander and invasion of the right of privacy.

    1. I agree
    2. I do not agree
64. Medical Authorization, Indemnity for Medical Expenses and Waiver*

    I understand the CITY cannot be expected to control all of the risks articulated in this form and the CITY may need to respond to accidents and potential emergency situations. Therefore, I give my consent for any medical treatment that may be required, as determined by a medical professional, during my/my child(ren)’s participation in the activity with the understanding that I will be responsible for the cost of any such treatment. I agree to indemnify and hold harmless the CITY for any costs incurred to treat me/my child(ren), even if the CITY has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation. I further agree to release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes the CITY from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by me/my child(ren) while receiving medical care or in deciding to seek medical care, including while traveling to and from a medical care facility, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of the CITY. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct.

    1. I agree
    2. I do not agree
66. Consent to obtain Medical Services*

    I give my permission to City of Dallas Park and Recreation Staff to call or obtain the services of a physician, or hospital for medical or surgical care for my child should an emergency arise. I understand that a conscientious effort will be made to locate all emergency contacts before any action may be taken.

    1. I agree
    2. I do not agree
68. Family Physician Name
69. Physician Phone Number
70. Preferred Hospital
72. Voluntary Signature*

    In signing this agreement, I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own free act and deed; the CITY has not made and I have not relied on any oral representations, statements, or inducements apart from the terms contained in this agreement. I execute this agreement for full, adequate, and complete consideration fully intending to be bound by all the terms in this agreement, now and in the future. I understand I can choose not to sign this agreement and free myself and my child(ren) from its terms and the associated risks of the activity by simply not participating in the activity and choosing some other activity available to me/my child(ren) that has a lower level of risk to myself and my child(ren). I further understand this activity is voluntary and extracurricular. While I understand alternative activities are available to me/my child(ren) that do not have the risks associated with the activity, I still desire to voluntarily engage/permit my child(ren) to engage in the activity.

    1. I agree
    2. I do not agree
74. Parent Info / Rules*

    I have reviewed the Parent & Participant Teen Tech Center program rules, Behavior Policy, and agree to comply with all policies & procedures for participation. I understand that I am financially responsible for any intentional property destruction or theft caused by me/my child.

    1. I agree
    2. I do not agree
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