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Steps

1. Organization Information This section is complete This section is incomplete
2. Contact Information This section is complete This section is incomplete
3. Number of Swimmers This section is complete This section is incomplete
4. Dates Requested This section is complete This section is incomplete
5. Rules and Guidelines This section is complete This section is incomplete

Organization Information

Name of Organization*
Organization Phone*
Organization Address*
City*
State*
Zip*
Organization E-mail*
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Contact Information

Contact Name*
Contact Phone*
Contact E-mail*
Second Contact Name
Second Contact Phone
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Number of Swimmers

Projected # of Swimmers*
Notes:
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Rules and Guidelines

Pleasant Green Pool Rules
Pool Rules
Please read before continuing.
Rules and Regulations*
I agree that I have read and understand all of the rules and regulations for Pleasant Green Pool, and I will ensure the staff within my organization, along with the children are aware and adhere to these rules as they are stated.
1. I Agree
Rule Compliance*
I understand that if my group is selected to swim at Pleasant Green Pool, my organization chaperones are responsible for ensuring the children are following all pool rules. I additionally understand that Pleasant Green Pool is not a babysitting facility, and my chaperones are required to be actively engaged with the children at ALL times.
1. I Agree
Arrivals and Departures*
I understand that if my group is selected to swim at Pleasant Green Pool I am required to adhere to the designated Arrivals and Departures schedule: group arrivals begin at 10:00am and departures from the facility will be no later than 3:30pm.
1. I Agree
Adult to Child Ratio*
I understand that if my group is selected to swim at Pleasant Green Pool I am required to adhere to the required adult to child ratio: a ratio of one adult chaperone for every ten children.
1. I Agree
Statement of Understanding*
I understand that if at any time my organization is not following the above rules and regulations as they are stated, I may be asked to leave the facility and forfeit any future scheduled times at the pool.
1. I agree
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I Agree
Electronic Signature*
Date*
Date

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Email address

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Pleasant Green Pool Child Care Provider Request Form

Steps

Organization Information

Contact Information

Number of Swimmers

Dates Requested

Rules and Guidelines

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