RHODINE ROAD NORTH COMMUNITY DEVELOPMENT DISTRICT AMENITIES ACCESS REGISTRATION FORM

NAME:

ADDRESS:

HOME TELEPHONE:	CELL PHONE:

EMAIL ADDRESS:

ADDITIONAL RESIDENT 1:	DOB IF UNDER 18

ADDITIONAL RESIDENT 2:	DOB IF UNDER 18

ADDITIONAL RESIDENT 3:	DOB IF UNDER 18

ADDITIONAL RESIDENT 4:	DOB IF UNDER 18

ADDITIONAL RESIDENT 5:	DOB IF UNDER 18

ACCEPTANCE:

I acknowledge receipt of the Access Card(s) for the above listed residents and that the above information is true and correct. I understand that I have willingly provided all the information requested above and that it may be used by the District for various purposes. I also understand that by providing this information that it may be accessed under public records laws. I also understand that I am financially responsible for any damages caused by me, my family members or my guests and the damages resulting from the loss or theft of my or my family members’ Access Card. It is understood that Access Cards are the property of the District and are non-transferable except in accordance with the District’s rules, policies and/or regulations, and any necessary replacement will be at an applicable Replacement Access Card fee. In consideration for the admittance of the above listed persons and their guests into the facilities owned and operated by the District, I agree to hold harmless and release the District, its supervisors, agents, officers, professional staff and employees from any and all liability for any injuries that might occur, whether such occurrence happens wholly or in part by me or my family members’ or guests’ fault, in conjunction with the use of any of the District’s Amenity Facilities (as defined in the District’s Amenity Policies & Rates), as well while on the District’s property. Nothing herein shall be considered as a waiver of the District’s sovereign immunity or limits of liability beyond any statutory limited waiver of immunity or limits of liability which may have been adopted by the Florida Legislature in Section
768.28 Florida Statutes or other statute.

Signature of Patron (Parent or Legal Guardian if Minor)	Date

AFFIDAVIT OF RESIDENCY: (REQUIRED IF LEGAL FORM OF PROOF OF RESIDENCY NOT PROVIDED)

I hereby state that the address listed above is the bona fide residence for all residents listed in this Amenities Access Registration Form and that such address is located within the Rhodine Road North Community Development District. I acknowledge that a false statement in this affidavit may subject me to penalties for making a false statement pursuant to Section 837.06, Florida Statutes. I declare that I have read the foregoing and the facts alleged are true and correct to the best of my knowledge and belief.

Signature of Patron State of Florida
County of 	

The foregoing was acknowledged before me by means of ▢ physical presence or ▢ online notarization this 	 day of 	, 20  , by
	 who is [ ] personally known to me or [ ] produced 	 as identification.
(NOTARY SEAL)

Official Notary Public Signature

RECEIPT OF DISTRICT’S AMENITY POLICIES AND RATES:

I acknowledge that I have been provided a copy of and understand the terms in the Amenity Policies and Rates of the Rhodine Road North Community Development District.

Signature of Patron
(Parent or Legal Guardian if minor)

Date

GUEST POLICY:
Please refer to the Amenity Policies and Rates for the most current policies regarding guests.

PLEASE RETURN THIS FORM TO:
Rhodine Road North Community Development District Attn: Amenity Access Team
219 East Livingston Street Orlando, Florida 32801
Answering Service: (689) 500-4540
Email: amenityaccess@gmscfl.com

ADDITIONAL INFORMATION:
Phase 	 – 	 Phase 	 – 		Phase 	 – 	
New Construction: 		Re-Sale: 		Prior Owner: 	
Rental: 		Landlord/Owner: 	
Lease Term: 	 Tenant/Renter: 	

Access Card #

PRIMARY RESIDENT:

Staff Member Signature

Date Entered in System

Date Received

OFFICE USE ONLY: