610-388-6787 (summer season only)

Dues And Registration Form – August Only

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Member Information

Family Name: ____________________________________________________ Phone: __________________________

Street Address:___________________________________________________

_______________________________________________________________

City: __________________________________ State: ______________ Zip:___________________________________

Email Address (GWSC Primary Method of Communications): ________________________________________________

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 List ALL family members living at the same legal address who will be attending the club in August. Member #1 must be an adult.

Member Name:______________________DOB: ___\___\___ Relationship to Member:_________________________

Member Name:______________________DOB: ___\___\___ Relationship to Member:_________________________

Member Name:______________________DOB: ___\___\___ Relationship to Member:_________________________

Member Name:______________________DOB: ___\___\___ Relationship to Member:_________________________

Member Name:______________________DOB: ___\___\___ Relationship to Member:_________________________

Member Name:______________________DOB: ___\___\___ Relationship to Member:_________________________

Total Bill for August Only Membership = $175.00

Please make check payable to Green Woods Club and mail to the address below. Your cancelled check is your receipt.

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Mitch Silverstein                                                  Pool Use Only

Membership Chair                                   Check # _____                     Note: Only those offered August

127 Ashford Drive                               Date Recd. __\__\2017        Only Membership by the Membership

Chadds Ford, PA 19317                                                                             Chair may complete this form. You

(610) 388-1822                                                                                              must be on the Wait List to receive

                                                                                                                              such an offer.
NOTE: Only those offered August Only Membership by the Membership Chair may complete this form. You must be on the Wait List to receive such an offer.

 

 

 

 

 

 

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EMERGENCY CONTACT & AUTHORIZATION CONSENT & MEDICAL REQUIRED IF: ANY CHILD REGISTERED IS UNDER 18 YEARS OLD

Accepting this August only membership does not change your placement on the wait list

If the child is under 12 and can be at the pool in the care of someone other than a parent, then that person must be at least 14 years old. The caregiver must be a member of the pool or the $7 guest fee applies.
Caregiver’s Name: _________________________________________________________If the child is age 12 or older, has passed the basic swim test and is to be at the pool without parental or caregiver’s supervision, please read and sign below.I give consent for my child to be at the Green Woods Club under the direction and supervision of the staff. I am aware that as a member of the pool (bonded or August only), I will be held responsible for my child’s actions and any damages that may be incurred by my child. I UNDERSTAND IF MY CHILD IS UNRULY, THIS PRIVILEGE MAY BE REVOKED AT THE DISCRETION OF THE POOL MANAGER .Bondholder’s Signature: ________________________________________________________
The following information applies to all children listed above under the age of 18.

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The following information applies to all children listed above under the age of 18.

Insurance Company: _________________________________________ Policy #:_________________________________

Doctors Name: _____________________________________________ Phone #: ________________________________

Please list below any and all health concerns, physical limitations and/or allergies (indicate which child this pertains to):

 ______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Medical Authorization:I understand that every effort will be made to contact parents/guardians in the event of an emergency. In an emergency requiring medical care and treatment, I hereby authorize any physician, hospital or other healthcare provider to give such care to this child. I also hereby give permission for the transport to/from a doctor and/or hospital by a staff member or ambulance.I do hereby release, discharge, and hold harmless the Green Woods Club Inc., its agents and employees, from any and all liability and claim either we or our child may suffer as a result of these requests for emergency treatment.The undersigned has read this Medical Authorization Consent Form and declares and affirms consent to the contents herein stated.

Parent / Guardian____________________________________________________ Date:______\___\________PLEASE RETURN THIS COMPLETED FORM WITH YOUR DUES AND REGISTRATION BY 3/1/ 2017 Thank you.

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PLEASE RETURN THIS COMPLETED FORM WITH YOUR DUES AND REGISTRATION Thank you.