STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR A SWIMMING POOL EXEMPTION STATUS 
WATER THERAPY FACILITY

This form is to be completed and submitted in duplicate, along with supporting documentation as necessary.

1.	Name of Pool      	

	Location of Pool      	 

2.	Name of Owner      	 Phone Number (   )     	

	Mailing Address      	 City      	 State   	 Zip      	

3.	THIS POOL MEETS THE FOLLOWING CONDITIONS FOR EXEMPTION QUALIFICATION:

	A. This pool will serve as a water therapy facility* connected with a hospital or Medical 
	      Doctors’ office(s)..	 Yes	 No

		( Attach supporting documentation: a written statement signed by a medical professional that they have 	    		already, or intend to prescribe medical water therapy for a patient in the pool, and a list of therapists or 			trainers)

	B. Any change in the exemption status of this pool will be reported to the County Health
		Department within 30 days.	 Yes	 No

*Water Therapy Facilities as that term is used in section 514.0115(1), F.S., are pools used exclusively for water therapy to treat a diagnosed injury, illness, or medical condition, wherein the therapy is provided under the direct supervision of a Florida licensed physical therapist, occupational therapist, or athletic trainer; pursuant to a prescription by a physician or a physician's assistant (PA) licensed pursuant to chapters 458 or 459, F.S., a podiatrist licensed pursuant to chapter 461, F.S., or an advanced registered nurse practitioner (ARNP) licensed pursuant to chapter 464, F.S.; and the prescribing physician, PA, podiatrist or ARNP, authorizes a plan of treatment justifying use of the pool for health care purposes.

CERTIFICATION OF OWNER

The undersigned owner, or owner’s representative, certify that this pool qualifies for exemption from supervision under Chapter 514, Florida Statute, and Chapter 64E-9 Florida Administrative Code.  If the exemption conditions change to eliminate the exemption status, this pool will be modified as necessary to comply with the provisions of the Chapter 64E-9 of the Florida Administrative Code. 
It will be the owner’s responsibility to inform any future owners of the conditions for this exemption status.

	Signature 	 Date 	

	Name/Title     	
		Please print or type
	
It is recommended that exemption status be  granted   denied, subject to the provisions of the Florida Administrative Code 64E-9,  and Florida Statutes 514.0115.
		
	DOH Engineer / Environmental Specialist
	     	
	Print Name