Pass # ______________
Mount Trashmore Park
310 Edwin Drive
Virginia Beach, VA 23462
Receipt# ____________
Date Issued __________
Williams Farm Park
5269 Learning Circle
Virginia Beach, VA 23462
SKATE PARK PASS APPLICATION
Woodstock Park
5709 Providence Road
Virginia Beach, VA 23464
rev. 1-Aug-16
Pass Types and Fees
Annual Youth - Resident
$20
Annual Youth - Non-Resident $40
Adult
Participant
Parent or
Guardian
Annual Adult - Resident
$30
Annual Adult - Non-Resident $50
Daily Youth - $3
Daily Adult - $5
Replacement Pass - $5
Last Name:
First Name:
Date of Birth:
Home Phone:
Work Phone:
Cell Phone:
Gender:
M
F
Gender:
M
F
Gender:
M
F
Gender:
M
F
Account Information
E-mail Address: (required)
Street Address:
Resident of Va. Beach
(Proof of Residency Required)
Non-Resident of Va. Beach
City:
Minor
Child 1:
Minor
Child 2:
Minor
Child 3:
State:
Last Name:
Zip:
First Name:
Date of Birth:
Home Phone:
Pass #
Last Name:
First Name:
Date of Birth:
Home Phone:
Pass #
Last Name:
First Name:
Date of Birth:
Home Phone:
Pass #
Emergency Contact:
Phone:
Relationship to Participant (printed):
Phone:
Assumption of Risk and Release Agreement
I, for myself and/or children, named here as a patron and/or participant in a Virginia Beach Parks and Recreation facility and/or program, am aware of
the possibility of accidental or other physical injury that may befall me or my child(ren) during use of the facility, equipment and/or program conducted by
this department, including programs sponsored by other agencies. I do hereby assume the risks of possible accidental injuries that I or my child(ren) may
suffer while utilizing Virginia Beach Parks and Recreation facilities and/or programs and release from any and all liability of cause of action, the City of
Virginia Beach, its employees and volunteers. Also, I hereby provide consent for the Department of Parks and Recreation to use photographs and/or
interviews with me in connection with publicizing or promoting the City of Virginia Beach, its services, or departments and agencies. I understand that
there is to be no remuneration for this use is reproduction of said photographs. In addition, I agree to follow all the rules and regulations established by
the Department of Parks and Recreation.
City of Virginia Beach Public Records
The records of the City of Virginia Beach are generally open to the public for inspection. State law allows the City of Virginia Beach to withhold email
addresses provided by citizens to the Department of Parks and Recreation if you specifically request in writing that such record(s) not be disclosed. If you
want to request that your email address not be disclosed, please check the box requesting the records be withheld and sign below.
Please withhold my email address.
Participant Signature:
Date:
Required if participant is under age 18. Parent or Guardian will be contacted to verify day pass information. Staff Verified(initial) ________Date _______
Parent or Guardian Printed Name:
Signature:
Date:
For Office Use Only:
Category 1:
Category 2:
DMV Driver’s License or DMV ID Card with Va. Beach Address
Non-Resident Driver’s License
Military ID
Photo ID and at least one from below:
Personal check with current address
Current lease/mortgage
Personal property tax bill
Current utility bill
Voter registration
Total # Passes Sold
Total Amount $:
Cash
Check #
Federal or State tax return
Current cable bill
Date Rec’d:
Current bank statement
Car registration
Staff Completing (please print):