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Pittston Playground Program
-Week Five Registration-

JULY 20-24 2026

**PLEASE NOTE - you MUST pay upon form submission for child to be accepted into this program**

Parent/Guardian First name*

Parent/Guardian Last name*

Parent/Guardian Email*

Parent/Guardian Phone*

Parent/Guardian Address*

How many children are you enrolling in the program? *

1

2

3

Child 1 Full Name*

Child One Birthday*

Month

Day

Year

Child 1 Gender*

Male

Female

Child 1 Medical Conditions/Allergies*

Is child 1 allowed to walk home*

Yes

No

Child 2 Full Name

Child 2 Birthdate

Child 2 Gender

Male

Female

Child 2 Medical Conditions/Allergies

Is child 2 allowed to walk home

Yes

No

Child 3 Full Name

Child 3 Birthdate

Child 3 Gender

Male

Female

Child 3 Medical Conditions/Allergies

Is child 3 allowed to walk home

Yes

No

Full name of additional emergency contact: *

Telephone # for additional emergency contact:*

Playground Program Payment*

Price per child$30

I understand that I MUST pay now for child to be accepted.

Downtown Pittston Partnership

(570) 299-7543

cwengen@pittstoncity.gov

71 S Main St

Pittston, PA 18640, USA

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Pittston Playground Program -Week Five Registration-

Downtown Pittston Partnership

Pittston Playground Program
-Week Five Registration-