Caregiver Access Form

Caregiver Access Form

This form must be completed by a registered MLRA member to request access for caretakers (e.g., aides, family members, babysitters) over the age of 21. Caretakers may accompany members children or act in an official capacity as an aide for members of any age.
Date Requested:*

MonthDayYear
Date
Parent/Guardian Information

The caregiver will be using this members card to gain entry to the facility.
Address:*

McKenzie Lake Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Members Name:*

First NameLast Name
Phone #:*

Area CodePhone Number
Email:*
By providing your email, you consent to receive all notices from MLRA via email, including invoices, updates, and announcements
Caregiver(s) Information

Access will only be granted to caregivers over the age of 18.
Caregiver Name:*

First NameLast Name
Caregiver Age:*
Caregiver must be over the age of 21
Additional Caregiver Name:

First NameLast Name
Caregiver Age:
Member's who will be accessing the facility with the caregiver

Members over the age of 12 can obtain their own membership card providing a parent or guardian signs the Children's consent form.
Name of member:*

First NameLast Name
Date of birth: *

MonthDayYear
Date
Name of member:

First NameLast Name
Date of birth:

MonthDayYear
Date
Name of member:

First NameLast Name
Date of birth:

MonthDayYear
Date
Name of Member:

First NameLast Name
Date of birth:

MonthDayYear
Date
I, Members name* permit Caregiver(s) name* to enter the McKenzie Lake Residents Association park and facility and use the McKenzie Lake Residents Association amenities with only the above mentioned residents.
I accept full responsibility for the actions and behaviour of the caregiver(s) and member(s) while they are accessing MLRA property.I am aware that all members and caregivers(s) are permitted to use MLRA amenities at their own risk and are subject to MLRA rules and regulations.I am aware that listed caregiver(s) are not permitted to rent boats, SUP boards.I am aware that caregivers are not permitted to sign in any guests, including their own children or dependants.
Members Signature:*

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Caregiver Access Form

Parent/Guardian Information

Caregiver(s) Information

Member's who will be accessing the facility with the caregiver