2011 Somerville Recreation Park &
Pool Registration
for (please circle all that apply) Lepp Park / Walck Park
(must be completed - with signatures - before individual may
swim at the pool) Non-Resident form available by contacting the Recreation Department)
Name: __________________________________________________________ Male _____ Female _____ Age _____
Address ________________________________________________________________________
Home # _____________ Cell # _____________
MEDICAL INFORMATION
Allergies____________________________________________________________________________________________
Special Medical Problems/Medications ____________________________________________________________________
__________________________________________________________________________________________________
IN CASE OF EMERGENCY CALL:
1. Name____________________________________________________ Relationship to registered: ______________________
Address ________________________________________________________Home # _____________ Cell # _____________
POOL AND PLAYGROUND RULES:
* All pool patrons MUST sign in daily to use the pool.
* Parents please watch your children.
* No jumping, running or diving in the pool !!!! Serious injury could occur.
* No breath-holding or prolonged underwater swimming.
* No rough play in or around the pool (including dunking). Serious injury could occur.
* No running. Please walk!!!!
* Slides may only be used when opened and supervised. Pay attention when on slide. Feet first entry and exit only. Head first entry/exit could result in serious injury. Please observe weight and height restrictions.
* Children 12 years and younger should be accompanied and supervised by an adult at all times around pool.
* Children must be potty-trained. No child with diapers (little swimmers etc.) are permitted in the pools. (baby pools only).
* No floatation devices (swimmies, tubes etc.). They are dangerous to users and other swimmers.
* No fighting or foul language.
* No glass bottles, alcoholic beverages of any kind, or smoking in the park.
* Everyone must take a shower (head to toe). Water quality is key to everyone's safety.
* Bathing suits must be worn in pool. No street clothes permitted.
* No eating or drinking inside the fence (pool area), other than water. Please use picnic tables in park area.
* Shoes should be worn at all times outside the pool area.
* Look and listen when the whistle is blown! Three whistles = EMERGENCY! Stop, clear the pool, listen!
* Obey all staff! Use of pool and park is a privilege not a right.
FAILURE TO OBEY THESE RULES WILL RESULT IN:
* In park penalty determined by the staff.
* Repeated offenders – Expulsion from the park. Return only after meeting between Director and Parent/Guardian.
I have read and understand all the pool and playground rules and will listen to the staff and obey the rules, so I will have a safe and fun summer! I understand it is a privilege not a right to use the parks and pools.
Youth Signature________________________________________________________________
Date _____________________
I give my consent for my child to participate in the activities at the Somerville Recreation Parks and Pools. I understand there are special dangers and risks in the activities at the parks and pools, including serious injury and death. I assume all risk of injury, damage and liabil-ity arising from these activities for my child.
As their parent/guardian, I herewith authorize the treatment of above child/children by a qualified or licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical im-pairment or undue discomfort if delayed. This authority is granted only after reasonable effort has been made to reach me.
Parent's Signature_______________________________________________________________
Date _____________________