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