City of Rochester EZ RecPass Registration Form
INSTRUCTIONS:	Fill in the form below. All fields marked with a red asterisk  *  are required. Click the "Save Information" button when done Print out the next page that displays. For youth ages 17 and under,  It MUST be signed by a parent or guardian to complete the registration process. Bring the signed page to your Recreation Center to receive your EZ RecPass

APPLICANT INFORMATION
* First Name:			Middle Initial:
* Last Name:			Nickname:
* Address:			* Zip Code:
* Gender:	- pick one - Male Female	*   Date of Birth:	* Race:	- pick one - Black Hispanic White Asian Other
School:			Grade:
E-Mail (use policy):			Phone:
Recreation programs of interest
FAMILY INFORMATION
* Parent/Guardian:			* Phone:
E-Mail (use policy):			Cell Phone:
* Employer (work):			* Work Phone:
Other relatives attending Center (name and relation):
EMERGENCY CONTACT INFORMATION
* Contact #1:			* Relationship:
* Telephone:			Telephone:
Contact #2:			Relationship:
Telephone:			Telephone:
MEDICAL INFORMATION
Please provide any Allergies or Health Problems that you would like us to be aware of:
Any Special Instructions: