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