“Family Fun Fair” Registration Form

August 11, 2012 – 11:00 a.m. to 2:00 p.m.

NAME OF PERSON OR AGENCY:                                                                                    

             Interested                    Not Interested in participating

ACTIVITY OR TOPIC TO BE PRESENTED:                                                                      

SPECIAL EQUIPMENT OR ACCOMMODATIONS:                                                          

IS THERE ANY COST FOR YOUR EVENT?                                                                     

PLEASE RETURN BY JUNE 30, 2012 TO:

Potter County Human Services

“Family Fun Fair”

62 North Street, PO Box 241

Roulette, PA  16746-0241