Centre Region Parks & Recreation
2643 Gateway Drive #1, State College, PA 16801       FAX 235.7832
CRPR Program Registration Form - Winter/Spring 2017

Please print this form, fill it out, and submit it via drop-off, fax or postal mail.
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Thursday, December 15, 2016       Active Guide distribution and registration via:
   A. 24/7 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 outer front 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)
Thursday, December 15, 2016        Phone 231-3071 & Counter Service Registration Begins (Mon.-Fri., 8 AM-5 PM)

To protect your personal & payment information, please do not email this form.
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.

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:  mo/yr   ___ /___
___ AMEX
Please Sign here:
Full Name of PARTICIPANT
Date of Birth if under 18
Entering Grade:
School
(Initials)

Gender M/F

T-shirt Size
(only if applicable)
First Choice Program #
Second Choice Program
#
FEE
(R/N)
                 
                 
                 
                 
                 
                 
Total Enclosed (Payable to CRPR)
$