2005 POOL APPLICATION

Newberry Station Pool Pass Application Form

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.

ANYONE WHO IS NOT IN GOOD STANDING WITH THE ASSOCIATION OR HAS VIOLATIONS STILL PENDING WILL NOT BE ISSUED A POOL PASS.  LANDLORDS ARE RESPONSIBLE FOR NOTIFYING THEIR TENANTS WHY THEY WILL NOT BE RECEIVING PASSES.

TENANTS MUST ALSO PROVIDE A COPY OF THE MOST RECENT LEASE IN ORDER TO OBTAIN A PASS.

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:  ___________________________________________________________

TENANT:  ____________  (COPY OF LEASE MUST BE ATTACHED)

RESIDENT OWNER:  ____________

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

E-MAIL ADDRESS:  ___________________________________________________