Unsupervised Minor Form – The Rutland Foundation

Virginia State statute does not set a specific age at which a minor (defined by Virginia as under the age of 18) may legally be left unsupervised. Legal guardians shall be liable for all minors left unsupervised at the pool (“Unsupervised Minors”). For guidance on who may be left unsupervised under the law, please consult section 2.4.2.2 of the Child & Family Services Manual detailing “Inadequate Supervision.” As minors cannot enter contracts or consent to risk, no guests that qualify as Unsupervised Minors (“Unsupervised Minor Guests”) may attend the pool without an Unsupervised Minor Guest Form.

Unsupervised Minor Guest Consent Form

Written consent is required for a guest who is a legal minor (under the age of 18) attending the pool as a guest of a member who is an unsupervised minor.

Minor's Full Name(Required)

First Middle Initial Last

Minor's Date of Birth(Required)

Minor's Age(Required)

Legal Guardian's Name(Required)

First Middle Initial Last

This field is hidden when viewing the form

Acct #

Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime & Evening Phone(Required)

Emergency Phone #1(Required)

Emergency Phone #2

Preferred Hospital(Required)

In case of an emergency, illness or accident to the above listed guest, pool management and/or Rutland Foundation staff members are authorized to contact the persons listed above. In case emergency attempts have been unsuccessful and it is necessary to take the child to the hospital, please specify preferred hospital:

Unsupervised Minor

The minor listed above is in my legal care and has my permission to swim as a guest at The Rutland Foundation pool without supervision. Legal guardians shall be liable for all minors left unsupervised at the pool (“Unsupervised Minors”) as it pertains to all state statutes. For guidance on who may be left unsupervised under the law, please consult section 2.4.2.2 of the Child & Family Services Manual detailing “Inadequate Supervision.” The above minor and legal guardian jointly accept all responsibility for the minor’s behavior and will ensure compliance with all of the pool rules and regulations of The Rutland Foundation. It is also understood that the manager and/or lifeguards on duty are fully authorized to enforce all rules and regulations and may temporarily suspend pool usage as they deem necessary.

Legal Guardian – Please enter your full name as your signature in the box below(Required)

Minor – Please enter your full name as your signature in the box below(Required)

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