Penn-Trafford Area Recreation Commission

 

REGISTRATION FORM
Instructions: Print and complete this form. Please use one registration form for each participant. When you are done, mail the form with the full payment to the address shown near the bottom of the form. Full payment is due at the time of registration. Please note that there are a maximum number of participants for each program.

Participant's Name: ___________________________________________

Male     Female

Street Address: _____________________________________________________________

City: ______________________      State: __________     Zip Code: _______________

Participant's Birth Date: _____________________      Age: _______     Grade: _______

Please circle where you live:     Penn Township     Penn Boro     Manor     Trafford     Non-Resident

Parent's Name (if participant is under 18 years of age): _________________________________

Daytime Phone: ______________________      Evening Phone: ______________________

Please indicate any medical conditions (including pregnancy) that PTARC and/or the instructor should be aware of:

________________________________________________________________________________
Check with your physician before beginning any exercise program. Handicapped assistance available upon request.

GOT A BUCK FOR THE PTARC/SHELLEY PROSKIN RECREATION CENTER?
Add $1 to your registration fee to help!

Program Name
(please indicate level when registering for swim instruction)

Start or Departure
Date

Start or Departure
Time

 Location Total Fee
per
Program
         
         
 Roster     Receipt Number ______________

* Adult participant's signature is required below. Parent's signature is required below for all participants under the age of 18.

The undersigned individual (parent or guardian if under age 18) represents that the registrant is in good health and can participate in the above listed activity and with prior knowledge of the physical nature of the activity releases Penn-Trafford Area Recreation Commission (PTARC), and Department, the Penn-Trafford School District, the Borough of Manor, the Borough of Penn, the Borough of Trafford, Penn Township, and/or its affiliates or subsidiaries, officers, directors, agents, or employees from any and responsibility for injury to the registrant through negligence or otherwise while he/she is participating in the activity. The parent, guardian, or participant assumes all risks inherent in the activity and will hold the Penn-Trafford Area Recreation Commission and Department, the Penn-Trafford School District, the Borough of Manor, the Borough of Penn, the Borough of Trafford, Penn Township, and/or its affiliates or subsidiaries, officers, directors, agents, or employees harmless from any and all claims or causes of action that may arise from this activity. The undersigned individual also hereby gives permission to Penn-Trafford Area Recreation Commission to use photographs of the participant for the promotion of Penn-Trafford Area Recreation events and programs. The participant agrees to hold the Penn-Trafford Area Recreation Commission, the Penn-Trafford School District, the Borough of Manor, the Borough of Penn, the Borough of Trafford, Penn Township, and/or its affiliates or subsidiaries, officers, directors, agents, or employees free and harmless from liability of any nature.

_______________________________________________________________________________
* Participant's or Parent's Signature and Date
  If under 18 years of age, the parent or guardian signature is needed

Please make checks payable to:
Penn-Trafford Area Recreation Commission (or PTARC)

Mail the form with full payment to:
Penn-Trafford Recreation, P.O. Box 452, Harrison City, PA 15636

Phone number: 724-744-2171 ext. 204 or 205     Fax number: 724-744-2172

After registering, plan on attending! You will only be notified
if the program is filled, postponed, or canceled.

-------------------------
REC. DEPT. USE ONLY
Refund Amount: ____________     Check #: ____________      Date: ____________