JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Borough of Shillington
Application for Pool Membership
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Membership Type:
*
New
Renewal
Other:
Membership Category
*
Family
Individual
Senior Citizen
Address:
*
Your answer
Phone Number:
*
Your answer
Email Address:
*
Your answer
Name: Father/Individual: If 65 or older, please provide your date of birth; Mother/Individual: If 65 or older, please provide your date of birth; Dependent Children under 18 years of age: (Name and date of Birth); College Age Students: (Name, date of birth, college attending)
*
Your answer
If this is a membership renewal, are there any differences from last year? If yes, please explain. (New address, new baby, overage dependent, divorce, etc.)
*
Your answer
Would you like to provide emergency contact information for the pool’s use:
*
Yes
No
Other:
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Governor Mifflin School District.
Report Abuse
Forms
