Form Center

2. Legal First Name*
3. Legal Last Name*
5. Birthdate*
7. Street Address*
9. City*
10. State*
11. Zip Code*
13. Primary Phone Number*
14. Phone Number
16. Email Address*
20. SilverSneakers Healthway ID Number
22. OR
24. Renew Active/One Pass Confirmation Code
25. United Healthcare Member ID
26. United Healthcare Group ID
30. Emergency Contact Information*
31. Phone Number*
32. Relationship*
36. Rules and Regulations
    All members agree to abide by the Recreation Department Facilities rules and regulation and Code of Conduct while in the facility. These rules and regulations may change from time to time. Failure to abide by the center rules and regulation may result in termination of membership.
38. Waiver of Claim
    The applicant warrants and represents the Parks, Recreation and Open Space Department that he/she is in good physical condition, suffering from no condition which would make participation at the facility harmful or dangerous. The member hereby waives any right of recovery or cause action against the Town of Parker, employees, or agents for any injury sustained by the member or for any physical condition created or aggravated by the member’s participation in the activities of the Recreation Facility. It is agreed that the Town of Parker Parks, Recreation and Open Space Department shall not be liable to members, their successors and assigns, for any injuries or any damage to members or be subject to any claim, demand, injury or damages resulting from acts of omission on the part of the Town of Parker, its officers, employees or agents. The Town of Parker shall not be responsible or liable for property damaged, lost or stolen in or about the Recreation facilities or lockers.
40. Severability
    In the event any part or parts of this agreement are deemed invalid or unenforceable, such part or parts shall be severed and remained of the agreement shall be in full effect. The Parker Recreation Department reserves the right to cancel this agreement at any time it deems that the conduct of the member is detrimental to the Recreation Facility and/or contrary to its regulation. If you are no longer deemed eligible for this program, your membership will be canceled.
42. Read the statements above.*

    1. I agree to the terms and conditions of the membership.
44. Signature*
45. Today's Date*
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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

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