2. ADAMSTOWN COMMUNITY POOL - 2023 Online Registration
4. ***WHEN FINISHED COMPLETING THIS FORM, PLEASE BE SURE TO CONTINUE TO MUNICIPAY PAGE TO MAKE YOUR PAYMENT***
6. DEFINITION OF FAMILY MEMBERSHIP: Up to two (2) parents or legal guardians and four (4) children 18 or under living in the same household or up to age 22 if enrolled in higher education with a valid ID. Additional children ages 5-18 living in the same household are $30/child. Guest passes are available for purchase on the payment page.
7. Please Select Applicable Membership Package Below
   -- Select One --Resident Family $235Non-Resident Family $300 Cocalico SD Family $280 Resident Adult $155 Non-Resident Adult $190 Resident Student/Senior $95 Non-Resident Student/Senior $130 Cocalico School District Student $120
9. First Name*
10. Last Name*
12. Address1*
14. Address2
16. City*
17. State*
18. Zip*
20. Phone Number *
21. Email Address
23. Please list names/ages of all members to receive pool passes below:
25. Waiver*

    1. I AGREE TO THE STATEMENT BELOW

    I have read and understand the Conduct and Safety Policies. I, and the members of my family, agree to follow them. I (we) also agree to follow the rules posted at the pool, and any special instructions given to me (us) by lifeguards. The information provided by me on this form is true and correct. ***I UNDERSTAND THAT FALSIFICATION OF RESIDENCY, AGE OR SCHOOL INFORMATION COULD RESULT IN THE SUSPENSION OF MY MEMBERSHIP WITH NO REFUND.*** SUBMISSION OF THIS FORM SERVES AS MY OFFICIAL SIGNATURE
27. First Name
28. Last Name
29. Age:
31. First Name
32. Last Name
33. Age:
35. First Name
36. Last Name
37. Age:
39. First Name
40. Last Name
41. Age:
43. First Name
44. Last Name
45. Age:
47. First Name
48. Last Name
49. Age:
51. First Name
52. Last Name
53. Age:
55. First Name
56. Last Name
57. Age:
59. First Name
60. Last Name
61. Age
63. Comments, Questions or Additional Children as defined in 'Family Membership' above & their Ages (Please contact the borough office for payment arrangements for all additional children listed below.):
65. *** AFTER CLICKING 'SUBMIT' PLEASE BE SURE TO COMPLETE PAYMENT ON MUNICIPAY PAGE. IF PURCHASING GUEST PASSES, REMEMBER TO CLICK THEM ON THE PAYMENT PAGE AS WELL ***
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67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

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