Saybrook Bath & Racquet Membership Form 2019
This form is used by the Saybrook Bath & Racquet Club Pool Board to keep updated information on members. A copy of the information will be kept on file at the pool in case of an emergency.
Email address *
Bondholder Information
Please list the bondholders and the address as it appears on your pool bond.
Bond #
Your answer
Membership Type
Primary Member First and Last Name
Your answer
Primary Member Date of Birth
MM
/
DD
/
YYYY
Primary Member Phone Number
Your answer
Primary Member Email Address
Your answer
Secondary Member First and Last Name
Your answer
Date of Birth Secondary Member
MM
/
DD
/
YYYY
Secondary Member Phone Number
Your answer
Secondary Member Email Address
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Youth Membership Information
For members under the age of 18 or full time students.
Child First and Last Name
Your answer
Child Date of Birth
MM
/
DD
/
YYYY
Child First and Last Name
Your answer
Child Date of Birth
MM
/
DD
/
YYYY
Child First and Last Name
Your answer
Child Date of Birth
MM
/
DD
/
YYYY
Child First and Last Name
Your answer
Child Date of Birth
MM
/
DD
/
YYYY
Child First and Last Name
Your answer
Child Date of Birth
MM
/
DD
/
YYYY
Child First and Last Name
Your answer
Child Date of Birth
MM
/
DD
/
YYYY
Nanny or Sitters
Please list the name of the adult care provider who may bring the children to the pool in lieu of the Bondholders.
First and Last Name
Your answer
First and Last Name (2nd Nanny or Sitter)
Your answer
Emergency Contact: In case of an emergency and we are unable to reach anyone at home please contact:
Emergency Contact Name
Your answer
Emergency Contact Phone Number
Your answer
Physician Name (for children)
Your answer
Physician Phone Number (for children)
Your answer
Please list any additional information in the event of an emergency. List any allergies to medicines or special medical conditions.
Your answer
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