REGISTRATION 2007

PLEASE COMPLETE ONE FORM PER PARTICIPANT OR STAFF/ CAREGIVER

REGISTRATION DUE ONE WEEK PRIOR TO CLASS START

(Click your Web Browser "Print" button to print the Registration Form) OR EMAIL US AT OFFICE@PACONNECTINGCOMMUNITIES.ORG

 

 

LAST NAME_________________________________________________________________________

 

FIRST NAME________________________________________________________________________

 

ADDRESS__________________________________________________________________________

 

CITY _______________________________________________ZIP___________________________

 

PHONE NUMBER____________________________________________________________________

ALTERNATE TELEPHONE NUMBER___________________________________________________

 

 DATE OF BIRTH __________________________________________AGE_____________________

 

E-MAIL_____________________________________________________________________________

 

AGENCY AFFILIATION _____________________________________________________________

 

TELEPHONE & CONTACT_____________________________________________________________

 

IF PAYING WITH WAIVER MONEY, AUTHORIZATIONS MUST ACCOMPANY ALL REGISTRATIONS or fax to (412) 784-1474.   PLEASE CONTACT YOUR ISC REGARDING YOUR AUTHORIZATIONS.

 

PLEASE LIST THE CLASSES & EVENT( S) YOU PLAN ON ATTENDING:

 

  1. _____________________________________________________________AGENCY / SELF PAY

 

  1. _____________________________________________________________AGENCY / SELF PAY

 

  1. _____________________________________________________________AGENCY / SELF PAY

 

  1. _____________________________________________________________AGENCY / SELF PAY

 

  1. _____________________________________________________________AGENCY / SELF PAY

 

DAY PROGRAM: (PLEASE CIRCLE AREA) – NORTH      SOUTH           EAST              WEST

 

PLEASE SIGN BELOW IF YOU DO NOT WANT YOUR PICTURE PUBLISHED IN ANY FORM OF MEDIA. 

 

 

PLEASE MAKE ALL CHECKS PAYABLE TO:

PA Connecting Communities ● The Sharpsburg Center ● 600 Clay Street ● Pittsburgh, PA 15215