Participants Name                                                                    Age                          Gender

Parent’s Name

Phone (H)                                                        (C)

E-Mail Address 

Home Address 

City                                      State                             Zip

Participant’s Skill Level                               Class Location and Day Preference


Any Medical Conditions 

Consent For Medical Treatment

I do hereby give authority to the SWIM4LIFE staff to obtain necessary emergency medical treatment for myself/my child  with the understanding that the family will be notified as soon as possible.


Relationship to Participant                                         Date 

Emergency Name                                                    Phone 

SWIM4LIFE, at times will use photographs and other form of media for marketing and advertisement purposes.  

Waiver and Assumption of Risk
I fully understand that there are certain risks and dangers associated with the facilities, instructions, equipment and/or activities that cannot be eliminated regardless of the care taken to avoid injuries and that these risks and dangers have been fully explained to me. I fully understand the risks and dangers involved. I fully assume the risks and dangers involved as acceptable to me, and I agree to use my best judgment in undertaking these activities, and I agree to follow all safety instructions. I waive, release, covenant not to sue, and agree to indemnify and hold harmless the business or organization from any claims, actions, suits, costs, expenses, damages or liabilities, including attorney’s fees for personal injury, property damage, accidents, illness, death, or any incidental damages that may arise from my use of the facilities or equipment or from my participation in the activities or receipt of instructions.  
I am a competent adult, age                    , and I assume these risks of my own free will for myself and/or my child. I have read this Waiver and Assumption of Risk and I understand its terms. I understand that I am giving up substantial rights, and I acknowledge that I intend by submitting this form that this be a complete and unconditional release of all liability to the greatest extent allowed by law.

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