Department of Parks & Recreation
Ross Township Municipal Center 1000 Ross Municipal Drive, Pittsburgh, PA 15237 Phone: 412.931.7041
PROGRAM REGISTRATION FORM
Please fill out a separate registration form for each participant and program. Acceptance of registration form is based on availability and first-come, firstserved basis, as some programs are limited in size. You many register via mail by check only. Program Registration is also available on-line at ross. pa. us – visit the Parks and Recreation tab; then navigate to the Programs section; choose a class category, then choose REGISTER NOW. Thank you!
Are you a resident of Ross Township? _____ Yes _____ No There is a fee difference for some programs- please check the class description.
Program Name: _________________________________________ Program Day: __________________ Program Fee: $______________
If this Program requires a township shirt or jersey please choose size: YS YM YL AS AM AL AXL A2X
Participant’ s Name: ______________________________________ Participant’ s Birthdate: ___/____/____ Sex: M ____ F ____
Parent / Guardian Name: ___________________________________ Phone:( H) _____________________( W / C) _____________________( If participant is under 18)
E-mail Address: _______________________________________________________
May we contact you via e-mail? ____ Yes ____ No
Street Address: __________________________________________ City / State / Zip: _____________________________________________
Emergency Contact: _____________________________________ Phone:( H) _______________
( W / C) ________________
Does participant have any medical concerns? If so, please list: _____________________________________________________________ oss Township
ROSS TOWNSHIP NEWS
Check here if you will need staff to contact you to discuss disability accommodation needs.
Liability Waiver
I give my consent for the above named person to participate in this program sponsored by the Ross Township Department of Parks & Recreation. I will not hold Ross Township, the Parks & Recreation Department, the Department’ s employees, coaches, volunteers, officials / umpires, other participants, or agents or employees of Ross Township responsible in the event of injury as a result of participation. I understand the risks involved and know the above named person is physically able to participate in the activity.
I further state that I have carefully read the forgoing liability waiver and know the contents thereof, and I sign the same as my own free act. I acknowledge that signature by either parent or by one guardian hereby binds all parents and / or guardians of any minor participant.
Permission to Use Image I grant Ross Township permission to use, for any legitimate reason, any photographs, motion picture, or recording of my participation in this activity.
_______________________________________________
Participant‘ s Signature( Parent / Guardian Signature if under age 18)
68 Ross Township
_______________ Date
For Office Use Only Date Rec.: ______________ Amount Paid: _____________ Cash / Credit / Check #_______________________________ Initials:_________________