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RECREATION CLASS INSURANCE PROGRAM INSTRUCTORS APPLICATION <br />CERTIFICATE HOLDER <br />Certlfloate Molder Name (City's Info hated on certlflcate): Clly of Santa Ana, Parke, Reoreatlon and Communlly Bolvlces Agoncy <br />Address; .20 CNIa Center Plaza (M-23) <br />City; santa Ana State; CA Zip: 92702 <br />Small;_. _ _ Phone; 71A671-4211 <br />Loention(s): Salgado Canter 706 N. N;MOPa al, Banta Are, CA 92703 <br />I._.JSAM Coverage (Sexual Abuse and Molestation) additional $00 upon initial request <br />[INaiver of Subrogatlon f Primary Endorsement (additional $136 upon Initial request) <br />ADDITIONAL INSURED: <br />Additional Insured Name (Instructor's Info): Hortenda Garcia <br />Address; 1604Wse1Cindy Ln Apt.D <br />City: Anaholm state: 2A_ Zip: 02802 <br />Email; hortencianunez.nb@0mag.com Phone: 71471a-40oa <br />Speolal wording_as required, bycl I .... _..... <br />_ .. . <br />PROGRAM DETAILS: Activity/ Program name: Latin ZUmba and Aerobics <br />Category from Approved Recreational Class LIBt Adrdt F1100M <br />!'lease /1st each now enroffinettf session perind. <br />W1/2026 <br />2/1 f2025 "a Oats:113112026 <br />Number of Estimated Reglsterbd Partlolpants & Instructor: 10 <br />Date: <br />L0Ft A <br />Payment Amount; $ llheok Enclosed ❑ZelleNenmo ❑Credit Card <br />Applicants Signature: Date; 1/8/2025 <br />Print Name: Hortencia Garcla Title: Instructor <br />Agency Representative's Name: <br />Phone#; 714718-4047 <br />Email: <br />41Page <br />i <br />i <br />I <br />