Alameda Recreation and Park Department - (510) 747-7529

WINTER BREAK TRIPS FOR TEENS/TWEENS (6TH TO 8TH GRADES)

Spend your some of your Winter Break with ARPD! On our first trip, we will travel to San Francisco by ferry for a day in the city. We will go ice skating at the Embarcadero Center and enjoy the sights and sounds of San Francisco. We will travel to San Jose's Tech Museum of Innovation to see "Mythbusters: The Explosive Exhibition". Put your scientific curiosity into action at this exhibit's West Coast debut. On our last trip, we will travel to Berkeley Ironworks to go rock climbing. We will then finish our day at Bay Street in Emeryville. Drop Off and Pick Up Tweens/ Teens at The Underground Teen Center (2203 Central Avenue, Alameda). Do not be late as we have a jam packed schedule ahead of us. NO REFUNDS ISSUED IF YOU MISS THE BUS. Participants should bring a lunch, spending money, and wear warm clothes, socks and comfortable walking shoes for all trips. There is a $1 per minute late fee payable that day for every minute you are late picking up your tween/ teen at the end of the day. Do not bring any electronic or sentimental items as ARPD Staff is not responsible for lost and/or stolen items. There is a $15 administrative fee for any cancellations or changes.

Trip #1 - FERRY TO SAN FRANCISCO & ICE SKATING

Class #11906

Thursday, December 27, 2012 - 8:00 am to 5:30 pm Fee: $50 / $60 after December 13

Trip #2 - SAN JOSE TECH MUSEUM Mythbusters: The Explosive Exhibition

Class #11925

Friday, December 28, 2012 - 8:00 am to 5:30 pm Fee: $50 / $60 after December 13

Trip #3 - BERKELEY IRONWORKS* & BAY STREET

Class #11907 Thursday, January 3, 2013 - 8:00 am to 5:30 pm Fee: $50 / $60 after December 20
*ADDITIONAL LIABILITY FORM REQUIRED FOR IRONWORKS Parents/Guardians must fill out online prior to trip at: http://www.touchstoneclimbing.com/ironworks/waivers

Please complete and return form with payment (cash, check made payable to ARPD, MasterCard or VISA) to the Alameda Recreation and Park Department, 2226 Santa Clara Ave, Alameda 94501. FAX registrations accepted with VISA/MasterCard: (510) 523-4071. Register online at: www.arpdeplay.com SAVE YOUR RECEIPTS! THERE IS A $5 SERVICE CHARGE PER RECEIPT TO REPRINT RECEIPTS. ARPD reserves the right to cancel programs due to low enrollment. Alternate programs may not be available.

I give my tween/teen permission to participate in the "WINTER BREAK TRIP(S)" sponsored by the Alameda Recreation and Park Department on:
r #11906 - SAN FRANCISCO FERRY & ICE SKATING - THU, DEC 27, 2012 - $50 PER PERSON ($60 AFTER DEC 13TH) r #11925 - SAN JOSE TECH MUSEUM & MYTHBUSTERS - FRI, DEC 28, 2012 - $50 PER PERSON ($60 AFTER DEC 13TH) r #11907 - BERKELEY IRONWORKS* & BAY STREET - THU, JAN 3, 2013 - $50 PER PERSON ($60 AFTER DEC 20TH) *ADDITIONAL LIABILITY FORM REQUIRED FOR BERKELEY IRONWORKS - Must be filled out online prior to trip ON THE TRIPS, MY TEEN: r MAY GO WITH A BUDDY OR r MUST STAY WITH LEADER AT ALL TIMES r ONLY LEAVE WHEN PICKED UP* AT THE END OF THE DAY, MY TEEN HAS PERMISSION TO: r CHECK SELF OUT OR

*List First and Last Name (s) Of All Person (s) Authorized To Pick Up Tween/Teen: (Late pick-ups are charged $1 per minute payable that day): ______________________________________________________________________________________________________________________

TWEEN/TEEN'S NAME:____________________________________________ BIRTHDATE: ______/_______/_______ AGE:_____ GRADE:_____

o MALE

o FEMALE

ADDRESS:_________________________________________________________CITY:_________________ZIP_____________HOME PHONE: (_______)___________________ Please note: Registrations for children requiring special attention are reviewed on a case-by-case basis with the Program Supervisor. Be sure to provide as much detail as possible, including any physical or emotional needs or medications involved. Recreation Department Staff do not receive specialized training for various special needs, but will work with individuals as appropriate to provide a positive experience. ALLERGIES, MEDICAL PROBLEMS, MEDICATIONS:______________________________________________________________________________________________________ MEDICAL RELEASE: I give permission for any certified emergency professional or health care professional to administer any type of medical treatment he/she deems necessary to the above child in case of an emergency and in the event that I cannot be contacted. DOCTOR'S NAME________________________________________________________________________ PHONE (_______)_________________________________________________ NAME OF INSURANCE__________________________________________________________________GROUP OR POLICY NUMBER____________________________________ 1. PARENT/GUARDIAN NAME_____________________________________________________ o MALE o FEMALE HOME PHONE: (_____)___________________

ADDRESS (if different)________________________________________________________________ WORK/CELL PHONE: (_______)_________________________________ 2. PARENT/GUARDIAN NAME______________________________________________________ o MALE o FEMALE HOME PHONE: (______)__________________

ADDRESS (if different)_________________________________________________________________ ORK/CELL PHONE: (_______)_________________________________ W IN CASE OF EMERGENCY AND PARENTS CANNOT BE REACHED, PLEASE CONTACT: (I understand it is my responsibility to provide current contact information) NAME:__________________________________RELATIONSHIP:_____________________HOME/WORK/CELL PHONE: (_______)_______________________________________
1. THE UNDERSIGNED HEREBY RELEASES, WAIVES AND DISCHARGES THE CITY OF ALAMEDA, its directors, officers, employees, agents, and independent contractors from all liability to the undersigned and/or his/her personal representatives, assignees, heirs, and next of kin for any loss or damage and any claim or demands accruing or resulting from injury to the person or property or death of the undersigned, whether or not caused by the negligence and/or property of the City of Alameda, its directors, officers, employees, agents, and independent contractors. 2. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE, whether or not it is due to the negligence of the City of Alameda, its directors, officers, employees, agents, and independent contractors or otherwise while in, upon or about the premises of the City of Alameda and/or while using the premises or facilities or equipment thereon. 3. THE UNDERSIGNED HEREBY PERMITS the taking of photographs of themselves and/or the participant by the City of Alameda during recreation classes or activities to be used at the City's discretion. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement has been made.

PARENT/GUARDIAN SIGNATURE_________________________________________________________________________DATE________________________
PAYMENT ENCLOSED: $_______ CASH___ CHK#_______ MC/VISA____________-_____________-______________-_____________EXP DATE__________