2005 POOL APPLICATION

Newberry Station Pool Pass Application Form

OUTSIDE MEMBERSHIP

Address: _______________________________________________________________

Adults over 18 Years of Age:

Name:  _________________________________________________________________

Name:  _________________________________________________________________

Name:  _________________________________________________________________

Name:  _________________________________________________________________

Young Adults Ages 13-18 Years of Age by DATE POOL OPENS:

Name:  ____________________________________            Birth Date:  ____/____/____

Name:  ____________________________________            Birth Date:  ____/____/____

Name:  ____________________________________            Birth Date:  ____/____/____

Name:  ____________________________________            Birth Date:  ____/____/____

Children ages 10-12 years of age by DATE POOL OPENS (must pass a proficiency test given by the lifeguard on duty before individual passes will be handed out, otherwise must be accompanied by an adult.)

Name:  ____________________________________            Birth Date:  ____/____/____

Name:  ____________________________________            Birth Date:  ____/____/____

Name:  ____________________________________            Birth Date:  ____/____/____

Name:  ____________________________________            Birth Date:  ____/____/____

CHILDREN UNDER 10 MUST BE ACCOMPANIED BY AN ADULT, 18 YEARS OF AGE OR OLDER.

POOL PASSES WILL BE MAILED AS SOON AS THE APPLICATIONS HAVE BEEN PROCESSED (ABOUT 2 WEEKS).  IF YOU DO NOT RECEIVE A PASS, YOU MAY PICK IT UP AT THE POOL NO EARLIER THAN THE DATE OF OPENING.

PLEASE SIGN AND RETURN TO: CARDINAL MANAGEMENT GROUP, INC., 5900 PRINCE JAMES DRIVE, SPRINGFIELD, VA 22152.  ANY QUESTIONS PLEASE CALL 703-569-5797.

I HAVE READ THE RULES AND REGULATIONS OF THE NEWBERRY STATION COMMUNITY POOL AND AGREE TO ABIDE BY THESE RULES AS STATED.  I WILL LISTEN TO ALL LIFEGUEARD INSTRUCTIONS AND UNDERSTAND THAT IF THESE RULES AND REGULATIONS ARE NOT FOLLOWED I MAY BE ASKED TO LEAVE AT ANY TIME AND MY POOL PRIVILEDGES MAY BE REVOKED FOR ANY PERIOD OF TIME DEEMED NECESSARY BY THE LIFEGUARDS OR OTHER GOVERNING BODY OF NEWBERRY STATION HOMEOWNERS ASSOCIATION.

ADULT SIGNATURE:  __________________________________________________

PRINTED NAME:  ______________________________________________________

ADDRESS:  ____________________________________________________________

PHONE NUMBER (H):  _____________________  (W):  _______________________

E-MAIL ADDRESS:  ____________________________________________________

MEMBERSHIP FEE: $250 FOR FAMILY PASS – MORE THAN TWO PEOPLE

                                    $175 FOR SINGLE PASS – TWO OR LESS PEOPLE

MAKE YOUR CHECK PAYABLE TO:            NEWBERRY STATION HOA

                                                                        C/O CARDINAL MANAGEMENT GROUP

                                                                        5900 PRINCE JAMES DRIVE

                                                                        SPRINGFIELD, VA 22152