Milford Recreation
Department Summer 2005
1 Union Square ~ Milford,
NH 03055
Phone
(603) 672-1067 ~ Fax (603) 673-2273
2005 Keyes Pool
As part of your Pool Pass Registration, you will
gain access to Keyes Memorial Pool in Milford
for open swim. Pool pass registration is
also required for participation in pool programs. Please sign the following
Pool Pass Registration to safely enjoy access to the Keyes Pool facility during
the scheduled hours.
Monday – Friday - 12:00-7:00 p.m.
Weekends – 11:00 a.m.-7:00
p.m.
WHERE
TO REGISTER:
Recreation Department at the Town Hall or Keyes Pool (during season)
·
Complete and return this Registration Form.
·
Provide proof of residency (for example, a copy
of a drivers license or utility bill showing a street address)
·
Include payment (checks made payable to “Milford
Recreation Dept.”). Returned Check fee
is $25.
Please fill in quantity of
each
Milford Residents
------------ $15.00 per
pass
-------------
$60.00 Family Pass (4 or more passes)
-------------
Free Age 4 and under
Non-Milford
Residents
------------- $30.00 per pass
------------- $120.00 Family pass (4 or more passes)
------------- Free Age 4 and under
Name Primary Pass Holder:
Address:
____________________________________________________Town: ________________________ZIP____________
Home
Phone Work/Mobile
Phone Email:
Emergency
Contact Name: Relation: Phone:
Additional Family Pass Members (Must be immediate family relation and live in same
household):
NAME:
______________________________________DOB: __________________RELATION:
_________________________
NAME:
______________________________________DOB: __________________RELATION:
_________________________
NAME:
______________________________________DOB: __________________RELATION:
_________________________
NAME:
______________________________________DOB: __________________RELATION:
_________________________
NAME:
______________________________________DOB: __________________RELATION:
_________________________
NAME:
______________________________________DOB: __________________RELATION:
_________________________
PERMISSION, EMERGENCY
TREATMENT & WAIVER AGREEMENT:
I AM AWARE OF the hazards of the activity/sport and
the risk of injury in this athletic program.
I certify that I am in good physical condition and am able to safely
participate in this physical activity/sport.
I HEREBY GIVE MY
PERMISSION for my
son/daughter to use the pool facilities provided by the Town of Milford
Recreation Department. I am aware of the hazards of pool activity and the
risk of injury. I assume all risks and
hazards incidental to such participation, and I do hereby waive, release
indemnify, and agree to hold harmless the said Town of Milford, its volunteers,
staff and all sponsors for all liability for any and all loss or damage, and
any claim arising out of injury to my son/daughter or property damage that
might occur, whether caused by negligence of the Town, agents or employees, or
during participation.
IN CASE OF
EMERGENCY, I hereby give my
permission to the program staff and medical personnel selected by the
Recreation Dept. and staff, in my absence, to act as my agent to apply simple
first aid when necessary, or in the event of a more serious accident, for my
child to be transported to an emergency medical facility to receive emergency
medical treatment. I also authorize the medical personnel to administer such
treatment as is medically necessary and I authorize the hospital to undertake
examination and emergency treatment, if warranted, on behalf of my child. IN
THE EVENT OF AN EMERGENCY, EVERY EFFORT WILL BE MADE TO CONTACT
PARENT/GUARDIAN.
PLEASE LIST ALL MEDICAL CONCERNS or
instructions the staff should know regarding your or your child’s health on the
back of this sheet (medications, allergies, behavior concerns, etc.)
Family Insurance Yes_______ No______
Company Name & Policy __________________________________
Participant Signature –
(Parent/Guardian must sign if participant is under 18):
____ Date
