Swim Lesson LEVEL 3 - JUNE 2022

LEVEL 3 - SWIMMING LESSONS

Becker Community Center Group Swim Lesson Registration
MONDAY-THURSDAY

JUNE 20TH - JUNE 30TH - 6:45PM - 7:30PM
Swim Lesson Level *

SWIM LEVEL 3 - JUNE 20TH - JUNE 30TH ~ 6:45PM - 7:30PM
*

MEMBER NON-MEMBER
Participant's Name *

First Name Last Name
Participant's Birthdate *

Month Day Year
Parent/Guardian Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number #1 *
Please enter a valid phone number.
Statement of Release

I agree to release the Becker Community Center, City of Becker, their employees and leaders of all liability related to accidents or injuries which myself or member of my family might incur while participating in the above mentioned activities. If necessary, I authorize the Becker Community Center to administer first aid and/or authorize medical treatment if this becomes necessary. Participants in the above-mentioned activities are not covered under the Becker Community Center’s or the City of Becker’s medical insurance policy

I, as the Parent or Guardian, give permission to the Becker Community Center, City of Becker, their employees and leaders of all liability related to accidents or injuries which myself or members of my family might incur while participating in any recreation program. In the event of injury or illness, every effort will be made to contact the Parents or Guardian. If necessary, I authorize the Becker Community Center to administer first aid and/or authorize medical treatment if this becomes necessary. Participants in the program are not covered under the Becker Community Center’s or the City of Becker’s medical insurance policy. If there is any need to contact the Parent or Guardian and they can not be reached, the BCC will contact the Emergency Contact. Only those listed who are authorized, will the child(ren) be released to with a photo I.D. I allow consent for the BCC staff to take photos of my child(ren) which may be used in marketing materials such as the seasonal brochure, flyer or City website
Parent/Guardian Name *

First Name Last Name
Signature *

signature required Clear
Payment must be made to confirm your BCC Swim Lesson Registration. You may call the BCC to pay, with a credit/debit card or BCC Staff will contact you to arrange payment. and to confirm registration and placement in class. Completion of this form does not guarantee placement in class. Placement in class will be confirmed by BCC Staff after payment has been received and class space is available.
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LEVEL 3 - SWIMMING LESSONS

MONDAY-THURSDAY