Brockport Pool Membership Application

Thank you for your interested in using the Aquatics facility at SUNY Brockport. Please complete the below application.

Pass Type

Please select your pass type from the options below - Yearly Pass OR Semester Pass
Yearly Pass
Semester Pass
If you selected Faculty/Staff, please include 800#
Applicant's Information
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Your Phone Number Your Phone Number - ### - ### ####
Your Email Address
Emergency Contact Information
Emergency Contact Emergency Contact First Last
Emergency Contact's Phone Number Emergency Contact's Phone Number - ### - ### ####
Additional Emergency Contact (Optional) Additional Emergency Contact (Optional) First Last
Additional Emergency Contact Phone Number Additional Emergency Contact Phone Number - ### - ### ####
Family Pass Information

If you selected a family pass option, please complete the below section
Name of Family Member #1 Name of Family Member #1 First Last
Name of Family Member #2 Name of Family Member #2 First Last
Name of Family Member #3 Name of Family Member #3 First Last
Name of Family Member #4 Name of Family Member #4 First Last
Membership Waiver
Thank you for choosing to use the Aquatics facility at SUNY Brockport. This waiver must be completed prior to use of the facility. Each member is required to sign in with the Lifeguard on duty, and present appropriate photo identification indicating their age. Members must be at least 17 years of age with appropriate identification in order to use the aquatic facility without a parent or guardian present. All guests are required to purchase a pass before using the facility. Guests are subject to all rules, regulations, and policies of SUNY Brockport. All persons under age 17 must have a parent, legal guardian or immediate family member present while using the facility. I declare that I intend to use the Aquatic Facility offered by SUNY Brockport Athletic Department and I understand that each person, (myself included) has a different capacity for participating in this facility. I assume full responsibility, during and after my participation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive while using the aquatic facility. I understand that part of the risk involved in undertaking any activity or program is relative to my own state of fitness or health (physical, mental, or emotional) and to the awareness, care and skill with which I conduct myself in that activity or program. I acknowledge that my choice to participate in any activity, service and program with the SUNY Brockport Aquatic Department brings with it my assumption of those risks or results stemming from the choice and the fitness, health, awareness, care, and skill that I possess and use. I recognize that by participating in the activities, facilities, programs, and services offered by the SUNY Brockport Aquatic Department, I may experience potential health risks such as transient light-headedness, fainting, abnormal blood pressure, chest discomfort, leg cramps, and nausea and I assume those risks willingly. I acknowledge it is my obligation to immediately inform the nearest Lifeguard of any pain, discomfort, fatigue, or any other symptoms that I may suffer during and immediately after my participation. I understand that I may stop or delay my participation in any activity or procedure if I so desire and that I may be requested to stop and rest by any Lifeguard who observes any symptoms of distress or abnormal response.
Applicant Signature (or parent/guardian if under 17)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY

Brockport Pool Membership Application

Pass Type

Applicant's Information

Emergency Contact Information

Family Pass Information