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  ($100 / 175)     PARENT & CHILD  ($75 / 125)     CHILD/STUDENT  ($40 / 60)

ADULT  ($50 / 70)                               SENIOR CITIZEN ($45 / 60)

PLEASE NOTE:  ONLY TWO ADULTS OR GUARDIANS ARE PERMITTED ON A FAMILY PASS

(EX:  GRANDPARENTS / MOTHER / FATHER / BABYSITTERS / OTHERS)

ALL CHILDREN ON A "FAMILY" PASS MUST RESIDE AT THE SAME ADDRESS ON A YEAR-ROUND BASIS

FIRST AND LAST NAME PLEASE

CHILD / STUDENT                                                            SENIOR CITIZEN                                          

PARENT OR

FAMILY PASS

ADULT #1                                                         ADULT #2                                                    

ADDRESS                                                                                                                         

CITY/STATE/ZIP                                                     TELEPHONE                                               

FAMILY PASS CHILDREN:

Birth certificates are required for all children UNDER AGE 18 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                                                               

 

COPIES OF BIRTH CERTIFICATES & PROOF OF RESIDENCY MUST ACCOMPANY THIS FORM WHEN MAILING OR FAXING

RESIDENCY - PROOF REQUIRED (Driver's License, Utility Bill, Tax Receipt)

CITY OF LATROBE               UNITY TWP               YOUNGSTOWN               DERRY               OTHER            

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