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Greenville Recreation Center
Program Registration Form

Program registration is not complete until payment is received by GALSA.  Payments can be made at the Greenville Rec Center business office between 9:00 AM and 4:00 PM Monday through Friday, or by mail.
Participants Name       Date
School District      Township     Child's Grade  
Child's Birthdate    Child's Age      Male Female     
Do You attend Kids Korner Day Care?  Y / N
Address   
City    State   Zip
Parent Name     Home Phone     Work Phone  
CELL PHONE      EMAIL  
Other person to contact in case of emergency
Name    Relationship    Phone  

Medical Record
Allergies:     Bee Stings       Insect Bites        Medication
Other physical limitations?
Is your child on medication? Y / N
If so, what?

Return Registration Form To:
In Person: Monday-Friday
9:00am - 4:00pm
At the Rec Center
*All hours subject to change*
By Mail: Galsa
P.O. Box 244,
Greenville, Pa 16125

Box MUST be completed by parent when registering, including free programs.
Program Time Program Fee Cost

Total 

Friends in Program
Comments

By hitting the submit button, I hereby give permission for my child to participate in GALSA Programs. I further release the Greenville Area Leisure Services Association and the Borough of Greenville from responsibility for any accidental injury which may occur to the participant as a result of participation in these programs. I also grant my permission to Greenville Area Leisure Services to use my name and photographs, videotapes or other recordings of my participation in this event for lawful purpose.