Resident User Information Form

Julington Creek Plantation Community Development District

Resident User Information Form

NOTE TO STAFF: This form may contain confidential information. Please do not disclose its contents without first consulting the District Manager.

PRIVACY NOTICE: Under Florida’s Public Records Law, Chapter 119, Florida Statutes, the information you submit on this form may become part of a public record. This means that, if a citizen makes a public records request, we may be required to disclose the information you submit to us. Under certain circumstances, we may only be required to disclose part of the information submitted to us. If you believe that your records may qualify for an exemption under Chapter 119, Florida Statutes, please notify the District Manager and complete the Address/Identification Confidentiality Request from Public Records Disclosure Form. PRIMARY PATRON INFORMATION (family members to be added to reverse side)

Last Name: ______________________________________

First Name: ______________________________________

Address: _______________________________________________________________________________

Street Address: __________________________________________________________________________

Apartment/Unit # TENANT INFORMATION (IF APPLICABLE)* ____________

Begin Lease Date: _____________

End Lease Date: _____________

Owner Last Name: ____________________________________

Owner First Name:_____________________________________

Owner Address:______________________________________________________________________________________________

Street Address:_______________________________________________________________________________________________

*Tenant shall provide a copy of their release and Owner shall submit a release form, see JCPCDD Assignment of Rights & Privileges Form

Apartment/Unit # EMERGENCY NOTIFICATION INFORMATION: _________

Home Phone Number: _________________________

Cell Phone Number: _________________________

Name" ___________________________________

Cell Phone Number: ___________________________________

Name: _______________________________________

Email Address(es): _______________________________________________

Please select all that apply:

 I would like to receive e-mails on District programs and events. (Do not check this option if you want the information in this section to be used only for emergency purposes.)

 I would like to receive text messages on District programs and events. (Do not check this option if you want the information in this section to be used only for emergency purposes.)

 Only contact me in case of emergency.

PRIVACY NOTICE: If you indicate that we should only use the Optional/Emergency Notification Information in case of emergency, then, pursuant to Section 119.071, Florida Statutes the Optional/Emergency Notification Information (which consists of the information in this section) may be exempt from disclosures we make as the result of a public records request. SPECIAL NEEDS

Does anyone in your family have special needs you would like us to be aware of?  YES  NO

If you answered yes, please provide specific information below in the blank space:

Julington Creek Plantation Community Development District

Resident User Information Form

HOUSEHOLD MEMBERS (Must Reside in Same House)

Name (Last, First)

Cell Phone

Birthdate

JCPCDD Resident*

1.

2.

Name(s) of Children

Cell Phone

Birthdate

3.

4.

5.

6.

7.

8.

*Non-Residents must complete the Non-Resident User Agreement and pay Annual User Fee.

**In the event that one of the cards is lost, we will be responsible in paying $5.00 for each replacement card.

_______________

Please initial

PLEASE READ AND SIGN BELOW:

The undersigned agrees and acknowledges that the above information is true and correct. It is understood that Resident Cards and Guest Passes are the property of the Julington Creek Plantation Community Development District (JCPCDD or District) and are non-transferable, in accordance with the District’s rules, policies and/or regulations. In consideration for the admittance of the above listed persons and their guests to utilize District property and District facilities, including without limitation the Aquatic Complex, Recreation Center and Sports Plex owned and operated by the JCPCDD (together, the Facilities), the undersigned on behalf of himself and/or herself and each of their minor children, heirs and successors, hereby agrees to hold harmless and release the JCPCDD, its staff, supervisors, agents, officers and employees, from any and all liability, claims, actions, suits or demands by any person, corporation or other entity for injuries, death, property damage or of any nature, arising out of, or in connection with use of the Facilities, including litigation or any appellate proceedings with respect thereto, except to the extent caused by the gross or intentional negligence of the JCPCDD. Furthermore, Patron understands that the District and its staff, supervisors, agents, officers and employees assume no responsibility for injuries or illness that Patron(s), or his or her minor children, may sustain as a result of individual physical condition or resulting from such person(s) participation in any activities, sports, use of pool, use of tennis or basketball court(s), use of playground, use of skate park, or other activities on District owned property. Patron expressly acknowledges on behalf of him/her self and his or her minor children, heirs and successors that he/she assume the risk for any and all injuries and illness that may result from participation in these activities. Patron hereby releases and discharges the District and its staff, supervisors, agents, officers and employees as a result of Patron(s), or his or her minor children’s, participation in these activities. Patron further understands that the District is not responsible for personal property lost or stolen while at the Facilities. By signing below, Patron(s) acknowledge he/she has received the JCPCDD rules and policies and shall abide by the same. Nothing herein shall be construed 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.

Print Name:

Signature: Date:____________________________ JCPCDD Employee Initials__________