Pool Membership Card Request Form

You must fill out and return this Assumption of Risk and RHONEWOOD Audio-video release form to the RPHA office.

Only permanent household residents who will use the pool may be added to the pool membership form. For Houseguest and Custodial Caregiver passes, please contact the business manager, Erika Taranowski, at 925-980-8767 or manager@rpha.info.

Please allow one to two weeks for completion. Note that once your pool card has been issued, a replacement fee will be charged for each card requested due to loss, damage, or other reasons.

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Number of Family Members

How many people in your family will use the pool?

Enter the family member's name(s) and birthday(s) if they are under 18.

Name(Required)

Birthdate

Name(Required)

Birthdate

Name(Required)

Birthdate

Name(Required)

Birthdate

Name(Required)

Birthdate

Name(Required)

Birthdate

Name(Required)

Birthdate

Name(Required)

Birthdate

Parental Work Phone Numbers and/or Local Emergency Contacts

Name

Phone

Cell Phone

Name

Phone

Cell Phone

Name

Phone

Cell Phone

Name

Phone

Cell Phone

Doctor

Phone

Dentist

Phone

Health Information

Please list any special health problems, severe allergies, or allergies to any medications for those requesting membership cards

Permission(Required)

Yes

In case of emergency, an effort will be made to notify you immediately. In the event we cannot reach you, we will attempt to contact the people listed above. If no one can be contacted above, is RPHA given permission to take your child to the hospital or doctor.

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