ROSSMunicipal
TOWNSHIP
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
Street Address: __________________________________________ City/State/Zip: _____________________________________________
Emergency Contact: _____________________________________ Phone: (H) _______________ (W/C) ________________
Does participant have any medical concerns? If so, please list: _____________________________________________________________
R O SS TOWN SH IP NE WS
oss Township
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)
58 Ross Township
_______________
Method: ¨Visa
Date
¨MC
¨Discover
¨Check
Check#_________________ Initials:___________________