REGISTRATION & LIABILITY FORM

Swimmer Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Swimming Pool Address (if different than Home Address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Name *

First Name

Last Name

Mother's Primary Phone Number *

(###)

###

####

Father's Name *

First Name

Last Name

Father's Primary Phone Number *

(###)

###

####

Emergency Contact #1 Name *

First Name

Last Name

Emergency Contact #1 Phone Number *

(###)

###

####

Emergency Contact #1 Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact #2 Name (not required):

First Name

Last Name

Emergency Contact #2 Phone (not required):

(###)

###

####

Emergency Contact #2 Address (not required):

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

MEDICAL AUTHORIZATION *

I understand that any medical condition or injury should be checked by a physician before participating in a swim program.

I authorize and give permission for the instructor, Lauren Park, to give and perform first aid to my child(ren), if required.

I understand that it is my responsibility to keep Lauren Park advised of any changes in my contact information, and that in the event that no one can be contacted; the instructor will phone EMS.

I authorize the physician and nursing staff to undertake examination investigation if necessary treatment of my child.

I authorize release of information to appropriate people (physician) as deemed necessary.

POLICY & LIABILITY *

CANCELLATIONS: I understand that lessons will not be made up unless cancelled by Lauren Park’s swim school.

REFUNDS: I understand that no refunds will be given for missed classes. A 50% refund will be returned if the session is cancelled by you at least one-week prior to the start date. No refund will be given if the session if cancelled by you after this date. A 100% refund will be given back of course if the session is cancelled by myself at any time.

PAYMENT: I understand that 50% of the total cost of lessons is non-refundable.

LATE FEES: I understand that a $15.00 charge per day will be added to the cost of lessons for late payments.

I agree that I have read the Swim Guide completely and understand all polices and programs. (www.laurenpark.ca/swim/)

I, the parent(s)/guardian(s) of the above-named swimming student, who is under the age of majority 18 years, do hereby release Lauren Park for and against any liability and all claims for damages or losses of any kind, which we and/or our child(ren) may suffer or incur arising from the above-named child(ren) participating in Lauren Park’s swim school. There are no medical reasons that we are aware of that would endanger the health and safety of the student(s) and instructor(s) when taking part in swimming lessons.

Printed Signature *

First Name

Last Name

Today's Date: *

MM

DD

YYYY