2018 WOMELSDORF SWIMMING POOL SEASON TICKET APPLICATION THE POOL IS A SMOKE-FREE FACILITY!

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1 2018 WOMELSDORF SWIMMING POOL SEASON TICKET APPLICATION THE POOL IS A SMOKE-FREE FACILITY! Cost for 2018 Pool Season: Per Person (over 3 years of age) $70.00 Please mail or bring your completed application, signed pool rules and payment (cash, check or money order) to Womelsdorf Borough, 101 W. High Street, Womelsdorf, PA, Applications will be accepted at the Pool. A completed application including signed pool rules, payment & dates of birth of minors must be included in order to process membership. Emergency contact information on the back of this application must be completed. Please list any Health Issues (Allergies, Hearing Problems, etc.) that Pool Staff may find helpful. Pool Memberships are NOT Refundable or Transferable. NAME:, LAST FIRST Address City Zip Phone# Work# Cell# ; Your will not be shared with anyone. Date of Birth (if a minor) ADDITIONAL MEMBERS Date of Birth (if a minor) PLEASE COMPLETE EMERGENCY INFORMATION ON BACK OF FORM & Return the Signed Copy of the Attached Pool Rules. Cash, Check or Money Order made payable to: Womelsdorf Borough Number of $70.00 Each = For a Total of $ ************************************************************************ Date Payment Received: Cash, Check/Money Order# Amount $

2 BOROUGH OF WOMELSDORF 2018-POOL - MEDICAL EMERGENCY FORM (Please Print or Type Information - One Form per member) MEMBER'S NAME: LAST FIRST Ml AGE: BIRTHDATE: ADDRESS: CITY: ZIP CODE: HOME PHONE: MEMBERS/PARENT CELL: MEMBER/PARENT WORK PHONE: Only Authorized Person(s) Listed Below May Sign-In/Out or Pick-up my child. (Must be 16 years old or older) List Full Name (and Relationship) - Will need to produce photo identification EMERGENCY CONTACTS (IF MEMBER CANNOT BE REACHED) NAME: ADDRESS: NAME: ADDRESS: RELATIONSHIP: PHONE: RELATIONSHIP: PHONE: MEDICAL HISTORY: IMPORTANT LIST (USE SEAPRATE SHEET IF NECESSARY) LIST ANY MEDICAL PROBLEMS, ALLERGIES AND MEDICATIONS YOU ARE CURRENTLY TAKING. PLEASE BE SPECIFIC! (Please Note: our pool staff are not authorized to give any medications (i.e. asthma inhalers, etc.)

3 DO YOU HAVE AN ALLERGIC REACTION TO BEE OR WASP STINGS? YES OR NO (Please circle one) IF YES, INDICATE ANY REACTIONS PHYSICIAN: PHONE: MEDICAL INSURANCE CARRIER GROUP NUMBER MEMBER/PARENT AUTHORIZATION FOR POOL STAFF TO ADMINISTER EMERGENCY TREATMENT: (i.e. CPR/First Aid or call Ambulance Signature of Parent or Guardian & Date Please also sign Womelsdorf General Pool Rules.

4 WOMELSDORF POOL GENERAL RULES (Please Read, Sign on Back and Return With Membership Application) 1. All bicycles shall be parked in the bicycle racks at the bike area. 2. POOL HOURS: as posted at the pool. The pool or any section may be closed for maintenance at the discretion of the Pool personnel or Borough Council. The use of the pool, when no regular lifeguard is in attendance is strictly prohibited. 3. HEALTH AND SAFETY RULES TO OBSERVE WHILE ON POOL GROUNDS: NO food or beverages of any kind in the pool premises. Inappropriate behavior will not be tolerated on pool premises and could lead to removal from pool premises. NO pets or animals on the pool premises. Admission may be refused to anyone with skin abrasions, colds, coughs, inflamed eyes, athlete's foot or to persons wearing bandages or children not wearing swimmers diapers, (which can be purchased at the pool for your convenience). Pool personnel shall be empowered to request clearing the pool to avoid fatigue or overexposure. All persons, including children, shall use the pool and its facilities at their own risk. Before entering the pool, patrons may be requested to use toilet facilities and take a shower, in order to maintain chemical balance within the pool. 4. LIFEGUARDS AND PERSONNEL: Guards are on duty to protect all pool patrons-when they are engaged in conversation their effectiveness is diminished, which may in turn endanger the lives of othersunless there is an emergency, please direct your questions to the on-duty manager or lifeguard who is on duty. a. Respect and obey all guards and personnel. b. If guard blows the whistle three times, leave the water immediately. c. Only authorized personnel are permitted on lifeguard stands. d. Guards and personnel have the right to ask swimmers to pass a swimming test for deep-water swimming. e. Only authorized personnel are permitted entrance to the filter and chemical rooms, kitchen, office area and guard room. The Three (3) foot area is for non-swimmers and parents with their children under the age of twelve (12).

5 Supervision of children under the age of twelve (12) is the responsibility of the adults bringing those children. DIVING BOARDS: SLIDING BOARDS: SPECIFIC RULES TO BE OBSERVED Rules to be followed as posted. Rules to be followed as posted. No children under the age of twelve (12) will be allowed on the pool premises without the attention of an adult (by law, an adult is defined as a person eighteen (18) years or older). The Womelsdorf Borough shall not be responsible for any accident, injury, theft or for so called-loss or damage to personal property on the premises of the pool. Cost of any property damage repair shall be charged to the responsible person. NO intoxicating beverages are permitted on the property. Admission will be refused to anyone showing visible signs of intoxication. The Manager has the right to limit the use of the telephone. No outgoing phone calls. NO littering is allowed - please use the trash and recycling receptacles. Swimmers shall wear proper swimming attire in the pool. Swim diapers must be worn by all toddlers not potty trained. Pennsylvania state regulations. Only children four (4) years old and under are allowed in the baby pool. Swimmers may only do front forward dives from the pool side in specified diving areas. NO DIVING in "RED LINE" areas. Pitching of tents of any kind is prohibited on pool property. NO SMOKING ON POOL PROPERTY including the parking lot. ADDITIONAL YMCA POOL RULES WILL APPLY. CHILDREN AGES 12 AND UNDER MUST MEET SWIM REQUIREMENTS DAILY TO UTILIZE ANY SECTION OF POOL FIVE (5) FEET OR DEEPER. THESE RULES MAY BE REVISED OR ADDITIONAL RULES ESTABLISHED AT ANY TIME BY THE BOROUGH. THE BOROUGH RESERVES THE RIGHT TO WAIVE ANY RULE IT DEEMS NECESSARY. By placing my signature on this form, I have read and will adhere to all of the above rules. This includes everyone listed on my membership. Date Signature

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