Registration and Waiver

Guardian's Name: *

Address (Street, City, State, ZIP): *

Phone: *

Email Address: *

Child 1 Name: *

Child 1 Age: *

Child 1 Birthdate: * 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 1950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010

Child 1 Swim Skill Description *

Child 2 Name:

Child 2 Age:

Child 2 Birthdate: 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 1950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010

Child 2 Swim Skill Description:

Lesson Time Availability (Please let us know what days and times throughout the week are available for your lessons. To save on gas and travel time for our instructors, we try and schedule lessons that are in close proximity to each other around the same times. However, we will accommodate to any time you provide within our control. Please let us know if you have flexibility in your scheduling.): *

Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relactionship to Student *

Please list any medical or other information about your child(ren) that may be helpful to us:

• I, the undersigned, as the parent or legal guardian of the children listed above, have my permission to participate in At Home Aquatics Swim School swim lessons. I assume full responsibility for all risks of injury or loss which may result from my son(s)/daughter(s) participation in this activity and hereby agree to hold harmless, release and forever discharge At Home Aquatics Swim School and their entire staff. I waive any and all claims and demands whatsoever which the undersigned and any of them or any third person of any accident, illness, injury or death of any person or persons, directly or indirectly from my son(s)/daughter(s) participation in the aforementioned program.
• I state to the best of my knowledge, my son(s)/daughter(s) listed on this form has no medical, physical, mental or emotional condition(s) which would hinder or prevent his/her active participation in all At Home Aquatics Swim School activities. In the event of any injury or illness, At Home Aquatics has my permission to administer first aid and whatever necessary treatment may be needed. If it appears serious and requires immediate attention, medical assistance will be necessary and the appropriate personnel will be contacted.
• I also give permission for photographs and video of my child(ren) to be used in print or broadcast media for the promotion of any At Home Aquatics Swim School activities.
• I have read and fully understand and I agree with the informed consent, release and the emergency medical authorization outlined above with regards to my son(s)/daughter(s). In addition, I understand and comply to/with all policies and procedures as outlined in At Home Aquatics Swim School registration packet.

By typing my full name I agree to the statement above: *

Date 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 20092010