ACCESSIBILITY & LANGUAGE

Concord 101 Registration Form

First Name
Last Name
Preferred name you would like it to appear on your name badge
If different from above. (nickname etc.)
Reside in City Limits

Yes
No
Mailing Address
Zip Code
Phone
Phone Number
Email
How long have you resided in Concord?
Occupation
Educational Background
Why are you interested in Concord 101?
Other past or present community activities:
Past City government service or involvement (such as serving on a board), if any:
Select the class you would like to attend.

Tuesday AFTERNOON class, 2:00 - 4:15 p.m.
Tuesday EVENING class, 6:15 - 8:30 p.m.
Do you have any dietary restrictions or food allergies?

Yes
No
If you answered yes, please list your allergies or restrictions below:
Terms

Please check the box to verify that you are 18 years of age or older. Class size is limited, and preference is given to City of Concord residents.
Notice: The City of Concord does not discriminate on the basis of age, sex, race, religion, national origin, or disabilities. If anyone needs special accommodations, please contact Lindsay Manson at 704-920-5210. This application may be available in an alternate format for users with special needs
Photo Release
I, the undersigned, hereby grant to the City of Concord permission to take photographs of me and use my likeness and of my child(ren) and his or her likeness, in the form of a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications for any legal purpose. I understand and agree that all photos will become and remain the property of the City and will not be returned to me.

I hereby authorize the City, to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness or the likeness of my minor child(ren)appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge the City, its officers, employees and agents from any and all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate or the estate of my child(ren) have or may have by reason of this authorization.

I HAVE READ THIS PHOTO RELEASE AND CONSENT FORM BEFORE AFFIXING MY SIGNATURE BELOW, AND I UNDERSTAND AND AGREE TO ITS TERMS. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW.
Photo Release Terms

I agree to the terms as listed.
Electronic Signature
Type Name for Electronic Signature

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Concord 101 Registration Form

Photo Release