REGISTRATION FORM
You can fill out this form, print it and mail it to:
LATROBE - UNITY PARKS & RECREATION
PO BOX 307
LATROBE PA 15650-0307

OR

 Fax it with your credit card information to:

724-537-2057

PARTICIPANT INFORMATION: (PLEASE NOTE: ONE REGISTRATION FORM IS NEEDED PER PARTICIPANT)
First Name: Last Name:
DOB: Age Phone:

Address:
City: State: Zip:
School: Grade: E-mail Address:
Parent Name:

Health Problems: Gender

Physician: Physician's Phone:
Emergency Contact:   Phone:
Residency: (Please Check One)
City ofLatrobe Unity Township  Other
 

In order for LUP&R & UWWC to better serve our community needs - please answer the following questions:

                    

                                     


Program: Fee: Add 10% if registering after the deadline
Program: Fee: Add 10% if registering after the deadline
Program: Fee: Add 10% if registering after the deadline
Program: Fee: Add 10% if registering after the deadline

TOTAL AMOUNT:

Shirt Size:         Short Size:

I, in consideration of my (or my child's participation) in this activity, hereby release Latrobe - Unity Parks & Recreation, the City of Latrobe, the Greater Latrobe School District, (at any program location) and any individual connected herewith from any and all property damage or liability arising from accident, injury or illness suffered as a result of participation in this activity.

Your Signature (Parent, if participant is under 18)

Payment Information:


Check Credit Card
Credit Card Type: Credit Card #: 

Expiration Date:   V-Code: (last 3 digits on back of card)  
Name on Card:

Billing Street Address :