City of Delaware Parks & Recreation Department SEASON PASS Jack Florance Pool POOL FORM 500 B. Lincoln Ave. Delaware, OH 43015 740-203-1460 PLEASE PRINT — Responsible Party: one = Address: City Zip: Home Phone: Cell: Emergency Email Addres: City Resident? Yes No Place of Employment: _ _ (nd gai of Ci Limi to ver residency) *RESIDENT [NON-RESIDENT ON REGULAR | PRE-SEASON ‘REGULAR SEASON Pass | PRESEAS ams a REGULAR AMT PAID | cipto Memorial Day) | (iter Memarat Day) | (Upto Memorial Duy) | ter Memorial Day) YouTH $04.50 ‘$105.00 121,50 $135.00 SINGLE | ADULT $99.00 $110.00 $126.00 $140.00 SENIOR $54.00 $ 60.00 $81.00 $90.00 2 $112.50 $125.00 $139.50 $155.00 *FAMILY 3 $130.50 $145.00 $157.50 $175.00 | of 4 $148.50 $165.00 $175.50 $195.00 S| __ $166.50 $185.00 $193.50 $215.00 "For familles of 6 or more, please add $10.00 per person* *Bamily—Immediate family only. No extended family. (This willbe verified), “Delaware City Resident—One who lives or work inthe city limits of Delaware and pays Delaware City Income Tax. (This willbe verified.) 1 DOB. Age: PRINT NAMES OF ALLFAMILY 2, - DOB. Age: MEMBERS, INCLUDING 3. — ——_____ DoB__Age: RESPONSIBLE pos ne PARTY, 7 Soo BL Age:__ = 6 DOB. - Age RELEASE OF ALL CLAIMS and PROMISE NOT'TO SUE: ive the sponsible pay: reas th City of Delaware, ther employes, gens, officers and servants ‘ofan risks and hazards indent to the above activity, and hereby forever fleas, wuive and velingush the Delaware Parks & Recreation Deparment andthe City of ‘Delaware ts instuctors and supervisors, and all eer persons assisting inthe condoct of sid activites to the paripant ise understand that because of roibive costs, no acide, heath oie isuranx covering the paricpantin his program will be procured und that our consent to the partipation ofthe above named participants) in his program is made with this undestanding upon signing the ck Florance Season Pass, the responsible party nd hee aly members have reseved knowledge, and gre o follow the ules and segulaions governing the use of Jack Flrance Poo. It is greed and understood that any vilationso hese rules may caus emiation ofthe agreement and ttl forfeiture of all Da ee, f any By executing ths agreement the espnsile party and fay members hereby sate Tha they understand the terms ofthe agreement and arcs 0 omply lly with al such vals and egulatons Signature of Responsible Party: Date: REFUNDS ARE NOT ISSUED ON POOL MEMBERSHIPS, _ AMT. PAM: curcx cast: pare: iMmmiatss Rupr canoe EXP. DATES rrr: wc Visa