CRPR Registration Form

Centre Region Parks & Recreation
2643 Gateway Drive #1, State College, PA 16801 FAX 235.7832
CRPR Program Registration Form - WINTER/SPRING 2012
Please print this form, fill it out, and submit it via drop-off, fax, or postal mail.
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Sunday, 18 Dec 2011       Active Guide distribution and registration via:
   A. Internet from www.crpr.org (this form is not required for Internet registrations)
    B. 24/7 Drop-Box at 2643 Gateway Dr. #1, State College, PA 16801 (Drop-box slot just left of outside doors).
    C. Mail to CRPR, 2643 Gateway Dr. #1, State College, PA 16801
    D. Fax to 814.235.7832 (Include credit card #, exp. date & Security Code)
Monday, 19 Dec 2011        Phone 231-3071 & Counter Service Registration Begins (Mon.-Fri., 8AM-5PM)
NOTICE: CRPR may take photographs and/or other moving or still images of the events it sponsors or the facilities it operates, and may use those images in promotional or other materials.
Note: To protect your personal information, please do not email this form to CRPR.

PAYER / PARENT INFORMATION

Full Name:

Mailing Address:

City: State: PA Zip:

Day Phone: Evening Phone:

Home E-mail Address:

RESIDENT OF: (Please check one)
__State College Borough	__College Twp.	__Harris Twp.	__Halfmoon Twp. (at Nonresident Rate)
__Patton Twp.	__Ferguson Twp.	__University Park	__Other (at Nonresident Rate)

PAYMENT METHOD:
__ CHECK	__ CRPR GIFT CERTIFICATE
__ MONEY ORDER	__ CASH (at CRPR Counter Only)
__ VISA	Name listed on card:
__ MASTERCARD	Credit Card Number:
__ DISCOVER	Security Code (3 digits): __ __ __ Exp. Date: m/d/yr ___ / ___ / ______
___ AMEX	Please Sign here:

Full Name of PARTICIPANT	Date of Birth	Entering Grade:	School (Initials)	Gender M/F	T-shirt Size*	First Choice Program #	Second Choice Program #	FEE
					-
					-
					-
					-
					-
					-
Total Enclosed (Payable to CRPR)								$

* Available for Coed Field Hockey only.