b'2022 Fall + Winter Programs THE TIMESProgram Registration FormPARTICIPANT PARTICIPANTFIRST NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ LAST NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DOB _ _ _ _ _ _ _ _ _ _ _ __ _ _ AGE _ _ _ _ _ _ _ CELL PHONE_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CELL PHONE PROVIDER_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (THIS ALLOWS US TO SEND TExT ALERTS FOR CANCELLATIONS)ADDRESS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CITY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ STATE _ _ _ _ _ _ _ _ ZIP CODE _ _ _ _ _ _ _ _ _ _ _ _ _ SCHOOL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ GRADE _ _ _ _ _ _ E-MAIL_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PRIMARY CONTACT _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DOB _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (PARENT/GUARDIAN)(PARENT/GUARDIAN)HEALTH PROBLEMS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ GENDER: n MALE n FEMALE REGISTERONLINE!EMERGENCY CONTACT _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PHONE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ RESIDENCY:n CITY OF LATROBEn GLSDn OTHER_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Program NameSessionFee1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ If you register after the deadline, please add $5 $ _ _ _ _ _ _ Would you like to donate to Parks & Recreation? Help us help others! Thank You! $ _ _ _ _ _ _ Would you donate to our Park Development Fund Help us keep our parks clean, modern and safe! $ _ _ _ _ _ _ Total: $ _ _ _ _ _ _ Shirt Size: Child / Adult Smalln Med n Large n xL n xxL n (please add $2 for xxL)Short Size: Child / Adult Small n Med n Large n xL n xxL n (Shorts for In-House Soccer ONLY)Release: I, in consideration of my (or my childs) participation in this activity, hereby release Greater Latrobe Parks & Recreation, the City of Latrobe, the Greater Latrobe SchoolDistrict (at any location) and any individual connected herewith from any and all property damage or liability arising from accident, injury or illness suered as a result of participation in this activity. I also permit the use of any photographs and videotape of me or my children for promotional purposes. The parent, guardian or participant assumes all risks inherent in the activity and will hold Greater Latrobe Parks & Recreation, its aliates, directors and employees harmless from any participant claims or causes of action that may arise from this activity and free and harmless from liability of any nature.X _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Signature (Parent/Guardian if under 18)PAYMENT INFORMATIONDate_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Check_ _ _ _ _Cash_ _ _ _ _Money Order_ _ _ _ _Visa_ _ _ _ _Master Card_ _ _ _ _Discover_ _ _ _ _ _ Credit Card #_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date_ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _ Name on Card_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Billing Street Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ V-Code (3 Digits on back of the card) _ _ _ _ _ _ __ _ _ _ _ _ _ Signature_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Greater Latrobe Parks & RecreationP.O. Box 307, Latrobe, PA 15650724-537-4331 (P)724-537-2057 (F)www.latroberecreation.orgcraig@latroberecreation.orgwww.latroberecreation.org724-537-433121 17'