Forest Hollow Membership Registration and Emergency Form

1. Forest Hollow Membership Registration and Emergency Form go online to www.ForestHollow.com to register If you are unable to register online please fill out this form Shareholder Dues ***Circle One*** Summer Member Dues Adult Single $275 Adult Single $325 Family of 4 or less $390 Family of 4 or less $460 Family of 5 $400 Family of 5 $480 Family of 6 or more $410 Family of 6 or more $490 Senior Single $235½ Summer $375 (5/29-7/11 or 7/12-9/6) Senior family of 2 $260 (Senior is age 65 and up) Inactive Fee $50 Please make check payable to FHSC My dues for 2010 are: _______ Please return completed form with Plus Winter Repair Fee: +$25.00 check to: Jonathan Lash Late Fee after May 1: _______ 6539 Oakwood Drive Check Total: _______ Falls Church, VA 22041-1129 Family Name:______________________ Address:__________________________________ Home Phone: _____________________ Email: ___________________________________ PRINT EACH FAMILY MEMBER’S NAME THAT IS LIVING AT ABOVE ADDRESS ONLY. (Include all family members, regardless of age) EMERGENCY CONTACT INFORMATION IS CRITICAL. I hereby authorize the lifeguard staff of NVPools, Inc. to obtain emergency medical care for injuries or illness for my child that might occur while at the pool facility. I direct all medical facilities to accept this document as authorization to render essential medical care necessary in the event of an emergency and I am unable to be immediately contacted. ________________________________ _______________ Signature Date Health Insurance Carrier ___________________________ Policy#______________