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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: user fee RATE
In Person: Monday-Friday
9:00am - 4:00pm
At the Rec Center
*All hours subject to change*		 $5 for BOROUGH RESIDENTS.
$10 for townships outside
of the greenville borough.
No user fee for a one time or
one day program.
By Mail: Galsa
P.O. Box 244,
Greenville, Pa 16125 		Registration is not completed until payment has been made.
A late fee of $5 will be charged after the program deadline.

Box MUST be completed by parent when registering, including free programs.
Program Time Program Fee User 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, the borough of Greenville, and the Greenville area school district from responsibility from 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 the event for lawful purpose.