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2. First Name
3. Last Name
5. Address
7. City
8. State
9. Zip Code
11. Is this your residence, business or place of employment?
12. Date of Birth*

    (MM/DD/YYYY)

14. Email Address
15. Phone Number
17. Why are you interested in attending Puyallup 101?
19. Background check authorization*

    Due to program participants' access to closed city facilities and offices, I acknowledge that the City will conduct a WA State Patrol background check on potential participants. Your DOB is required for this background check.

    1. Yes
    2. No
21. Participant Waiver and Release*

    I am 18 years of age or older or attending with a legal guardian, fully competent and I desire to participate in the City of Puyallup civics course, Puyallup 101. 

    I am fully aware of the fact that there are special dangers and risks inherent in this activity, including, but not limited to, the risk of physical injury or other harmful consequences that may arise or result directly or indirectly to me from my participation in this activity. Being fully informed as to these risks and in consideration of my being allowed to participate in Puyallup sponsored activities and/or use of Puyallup facilities, I hereby assume all risk of injury, damage and harm to myself arising from such activities or use. I also hereby individually and on behalf of my heirs, executors and assigns, release and hold Puyallup harmless, as well as its officials, employees, volunteers and agents and waive any right of recovery that I might have to bring a claim or lawsuit against them for any personal injury, death or other consequences occurring to me arising out of my voluntary participation in this activity.

    *Please note that consent is required to attend Puyallup 101.

    1. Yes, I do hereby consent.
    2. No, I DO NOT consent.
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field