Emergency Care – Hollin Hills Pool

Acct #

Swimmer's Name*

First Last

Swimmer's Date of Birth*

Parent/Guardian 1 Name*

First Last

Parent/Guardian 1 Phone*

Parent/Guardian 2 Name

First Last

Parent/Guardian 2 Phone

Emergency Contact Name*

First Last

Emergency Contact Phone*

Physician Address and Phone*

List known allergies to medications:

List known allergies to insect bites, bee stings, etc.:

List medications taken on a daily basis:

Agreement and Approval*

I authorize a member of the HH Pool staff to seek medical assistance for my child when I or my emergency contact cannot be contacted.
Checking this box and clicking submit serves as a legal signature for this electronic form. The form will be date stamped and kept on file for the 2019 pool season.