R OSS TOWN SHI P N E WS
Ross Township Community Center
1000 Ross Municipal Drive
Pittsburgh, PA 15237
Phone: 412.931.7041 or 412.931.7055 x204
PROGRAM REGISTRATION FORM (PLEASE PRINT)
YOU MAY COPY THIS FORM FOR ADDITIONAL PROGRAMS
Please fill out a separate registration form for each participant and program. Feel free to copy this form, request additional forms, or download from
the Township’s website (www.ross.pa.us), if needed. Acceptance of registration form is based on availability and first-come, first-served basis, as some
programs are limited in size. Make all checks payable to Ross Township Recreation. NSF Fee of $25 for returned checks.
Are you a resident of Ross Township? _____ Yes _____ No
Non-Township residents are subject to an additional fee.
Program Name _________________________________Program Times/Dates ______________________ Program Fee: $_____________
Participant’s Name _____________________________ Participant’s Birthdate: ___/____/____ Age:_____ Sex: M____ F ____
Parent/Guardian Name ____________________________________________ Phone (H) __________________ (W) _________________
(If participant is under 18)
Street Address ___________________________________________________ City/State/Zip ____________________________________
Emergency Contact _________________________________________ Phone (H) ____________________ (W) ___________________
Does participant have any medical concerns? If so, please list:_____________________________________________________________
E-Mail Address (This information is secure, it WILL NOT be shared):__________________________________________________________
_____ Check here if you will need staff to contact you to discuss disability accommodation needs.
T-Shirt Size (If applicable) YS YM
AS AM AL AXL
OTHER SIZE______ (Additional Charge of $2)
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.
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