|
Mt. Horeb Family Aquatic Center Pool Pass This form, along with the emergency form, must be filled out to receive a pass. . Check one: Individual pass___________ Family pass__________. Check one: Mt. Horeb Resident(within school district boundaries)______ Nonresident______. Last name:______________________ Village/Township:______________________ . Address:________________________________________________________ (P.O. Box not accepted) street city zipPhone:________________________ . First and Last names of pass holders: Adult: ______________________________ Age:______ Relationship:_____________ Adult: ______________________________ Age:______ Relationship:_____________ Children:____________________________ Age:______ Relationship:_____________ Children:____________________________ Age:______ Relationship:_____________ Children:____________________________ Age:______ Relationship:_____________ Children:____________________________ Age:______ Relationship:_____________ Children:____________________________ Age:______ Relationship:_____________ Children:____________________________ Age:______ Relationship:_____________ . Read before signing: I understand that all persons listed above will have a pass card if over the age of 8. I also understand if I forget my card, I will be charged the daily admission fee and lost cards will cost $5.00 to replace. I also certify that all persons listed above are immediate family members only (2 adults and children under 18). Passes are non-transferable and are to be used only by the persons listed above. All information must be completed to obtain a pass. False information will result in loss of pool pass. . Signature:__________________________________________ Date:_____________________ . Total Payment:__________ Cash / Check #_________ Receipt #___________ Pass #_________ Emergency Form______
|