Orinda Park Pool Emergency Contact Sheet

Orinda Park Pool Emergency Contact Sheet

Please Fill Out All Information
Stockholder First Name
Stockholder Last Name
Stockholder First Name (2)
Stockholder Last Name (2)
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Other Phone

Area CodePhone Number
E-mail (1)
E-mail (2)
Membership Type
Family: Please list all names, including certificate holder. Any other individuals accompanying you to the pool will be required to pay a $5.00 guest fee. Family members must reside in the family home with exception of college age children.

Au Pairs: Please include names of AuPair/Nanny/Babysitter. There is an additional $100 fee for childcare providers. Please note name with family members below.

Guests are not allowed to use the pool facilities without an adult member sponsor present.
Membership Includes (provide names):
In case of emergency, notify:
Doctor's Name
Doctors's Phone Number

Area CodePhone Number
In case of minor problem, and OPP is unable to contact me, please notify:

(please provide Name, Phone Number, Address)
Friend/Relative Contact Info
In an emergency when I cannot be reached
and our family physician is not available,
I give my permission to use closest medical personnel available:
Waiver and Release of Liability:

I understand that my use of Orinda Park Pool carries with it a potential risk of injury. On behalf of myself and my heirs, dependents, and next of kin, I hereby release, discharge, and hold harmless, Orinda Park Pool Inc., a California non-profit corporation, its officers governors, agents, and employees from any and all claims that I might later have as a result of my use of Orinda Park Pool.
Electronic Signature Box
Certficate Holder's Signature
Date

MonthDayYear
If you are submitting this form electronically, please check the electronic signature box then type your name in the signature box. By doing so you are authorizing Orinda Park Pool to use your authorized "electronic signature".
Should be Empty: