Receipt # Date:
ROGERS - McFEELY MEMORIAL POOL
PASS REGISTRATION FORM
|
PLEASE CIRCLE ONE - Fees are based on residency: Those residing in the Greater Latrobe School District - 1st Fee Those residing outside the Greater Latrobe School District - 2nd Fee FAMILY ($125 / 200) PARENT/NANNY & CHILD ($100 / 125) ADULT ($60 / 80) CHILD/STUDENT ($50 / 70) SENIOR CITIZEN ($50 / 70) |
PLEASE NOTE: A FAMILY MEMBERSHIP INCLUDES UP TO 4 MEMBERS, AND CAN INCLUDE CHILDREN UNDER AGE 22. ADDITIONAL FAMILY MEMBERS CAN BE ADDED TO THE PASS FOR A FEE OF $15 EACH.
Two adults can be included on a family pass and may include guardians other than parents:
GRANDPARENT / BABYSITTER / NANNY / OTHER
THE CHILDREN ON A "FAMILY" PASS HOWEVER, MUST RESIDE AT THE SAME ADDRESS ON A YEAR ROUND BASIS.
FIRST AND LAST NAME PLEASE
FAMILY PASS
ADULT
#1
ADULT #2![]()
Birth certificates are required for all children UNDER AGE 22 residing at the same address:
|
NAME Date of birth NAME Date of birth
NAME Date of birth
|
NAME Date of birth NAME Date of birth
NAME Date of birth
|
STUDENT
PASS (name)
ADULT
PASS (name)
![]()
SENIOR CITIZEN PASS (name)![]()
PARENT/NANNY
& CHILD PASS (ADULT)
(CHILD)![]()
ADDRESS
CITY
/ STATE / ZIP
![]()
TELEPHONE
EMAIL
|
MEDICAL INFORMATION: Please list any medical problem the Parks & Recreation Staff should be aware of:
EMERGENCY CONTACT: TELEPHONE FAMILY / CHILD'S PHYSICIAN TELEPHONE PARENTAL SIGNATURE |