Pool Registration Form                                 Date ____________

Family Last Name _______________ Mother's Name _________ D/O/B  _______ Father's Name ___________D/O/B _____

Child's Name ______________ D/O/B _____ Child's Name _____________D/O/B ______ 

Child's Name ______________ D/O/B _____ Child's Name _____________D/O/B ______ 

Child's Name _____________D/O/B ______  Child's Name _____________D/O/B ______ 

Address _____________________________________________  Home Phone # ___________________________

MEMBERSHIP: (Please circle)

                    Family             $300.00   Individual (over 12)     $175.00    Individual (under 12) $90.00    Senior  $35.00     

                    Wading Pool   $60.00     Wading Pool 2^nd child $20.00      Daily Card Holder      $40.00

MEDICAL HISTORY: Dr. Name _____________________ Dr. Phone Number _____________________


Heart Condition _____ High Blood Pressure _____  Seizure Disorder ______  Diabetic _______  Allergies ______

Hearing Impairment _____  Physical Disability _____ Other ________________________________

Do you or any member of your family take medication: (Please use other side for more room.)

___________________________________                      _________________                                          ______________     
Name of Medicine                                                                 Dosage                                                                  x's Per Day             

___________________________________                      _________________                                          ______________
Name of Medicine                                                                 Dosage                                                                  x's Per Day             

As a participant in the above program, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risks of any injuries, damages or loss which I or my child may sustain as a result of such participation. I further understand that the Village of Dobbs Ferry does not provide accidental medical coverage and it is my responsibility to provide appropriate coverage. I agree to waive and relinquish all claims and hold harmless the Village of Dobbs Ferry, Parks and Recreation Department, its officers, agents and employees from any and all claims.

________________________________________________________                 _______________________
Signature                                                                                                                 Date