Department of Parks & Recreation
Ross Township Municipal Center 1000 Ross Municipal Drive, Pittsburgh, PA 15237 Phone:( 412) 931-7041 or( 412) 931-7055 x204
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.
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 Times / Dates: __________________ Program Fee: __________
Participant’ s Name: ______________________________________ Participant’ s Birthdate: ___/____/____ Age: _____ 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 oss Township
ROSS TOWNSHIP NEWS
Street Address: __________________________________________ City / State / Zip: _____________________________________________
Emergency Contact: _____________________________________ Phone:( H) _______________
( W / C) ________________
Does participant have any medical concerns? If so, please list: _____________________________________________________________
Check here if you will need staff to contact you to discuss disability accommodation needs.
School / Community Partnership
Children are expected to act responsibly at all times and in all areas of our community. To foster appropriate behavior in the community and in the school, the child and parent agree to immediately report the child’ s school suspension and / or expulsion to the Parks & Recreation Department. The child will be barred from participation in Department activities until the completion of the suspension or, if expulsion, until acceptance into an alternative education program. Failure to inform the Parks & Recreation Department will result in immediate removal from the program.
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.
For Office Use Only
Date Rec.: ______________ Amount Paid: _____________
_______________________________________________
Participant‘ s Signature( Parent / Guardian Signature if under age 18)
_______________ Date
Method: ¨ Visa ¨ MC ¨ Discover
Initials:_______
¨ Check- Check # _________________________
Ross Township | Spring 2017 | icmags. com 69