DANSWIM.COM MEMBER INFORMATION AND WAIVER OF LIABILITY AGREEMENT
Applicant's Name
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Email
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example@example.com
Phone
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Applicant's Date of birthday
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Month
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Day
Year
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Address/City/State/Zip
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EMERGENCY CONTACT
Emergency contact Name
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Emergency contact Phone
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Relationship to contact
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MEDICAL HISTORY
Please list all conditions, impairments, injuries, and surgeries (including but not limited to pregnancy, serious allergies, low/high blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, etc.).
Check the box. If you don't have any check the "NONE" box
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Heart attack, coronary angioplasty, or cardiac surgery
Lightheadedness or fainting with exercise
Pulmonary disease (asthma, emphysema, bronchitis)
High blood pressure
Anemia
Abnormal blood lipids (evaluated cholesterol and/or triglycerides)
Recent illness, hospitalization or surgical procedure. If yes, put it in others line?
Taking medication. If yes, put it in others line?
Chest discomfort, especially with exercise
Heart muscle, clicks, or unusual cardiac findings
Stroke
Diabetes
Emotional Disorder
NONE
Other
CHILDREN NAME
Children’s Information: Please list children’s names and date of birth (if they will be attending classes at DANSWIM)
Child's Name 1
Child's DOB 1
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Month
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Day
Year
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Child's Name 2
Child's DOB 2
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Month
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Day
Year
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Child's Name 3
Child's DOB 3
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Month
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Day
Year
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HOW DID YOU HEAR ABOT DANSWIM
Please check the box or add your own response in "Other" field
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Social Networks (Instagram, Facebook, Youtube)
Google
Friends recommendation (please mention friend's name in the "Other" field
Other
RELEASE OF LIABILITY & PARENT/GUARDIAN’S AGREEMENT/AUTHORIZATION/RELEASE:
I. I FULLY UNDERSTAND THAT: (a) WATER RELATED ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENTDISABILITY, PARALYSIS, AND DEATH (“RISKS”); (B) these Risks and dangers may be caused by my own actions or inaction’s, the actions or inactions’ of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be OTHER RISK AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the Activity. II. I hereby assume all of the risk of participating in swim lessons and acknowledge that the Instructor is not responsible for any injuries resulting from my child or the property owner’s negligence. III. I also understand that Swim and the city ©, the property owner, and the property manager are not responsible for any damages or loss to person or possession while on the premises.PLEASE READ CAREFULLY. THIS RELEASE OF LIABILITY CONTAINS A RELEASE OF KNOWN AND UNKNOWN CLAIMS BY YOU AND YOUR CHILD. I RECOGNIZE THAT BY SIGNING THIS DOCUMENT, I AM WAIVING CERTAIN LEGAL RIGHTS, INCLUDING ANY RIGHT I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST Swim and the city ©. I INTEND FOR MY AGREEMENT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF LIABILITY OF Swim and the city © TO THE GREATEST EXTENT PERMITTED BY LAW. I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THIS RELEASE OF LIABILITY, AND KNOWINGLY AND VOLUNTARILY SIGN BELOW:
Signature of Participant or Parent/Guardian if Participant is under 18
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DATE (date when signed this form)
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Month
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Year
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1. Application of NYS Law. This Agreement and the interpretations hereof, shall be governed exclusively by its terms and by the laws of theState of NY, without reference to its choice of law provisions.2. Survival. I agree that my obligations detailed herein shall continue in effect after termination of this Agreement, regardless of the reason, and whether such termination is voluntary or involuntary.3. Severability. In the event that any provision of this Agreement is deemed unenforceable, the remaining portions of the Agreement shall be severed and remain in full force.4. Binding Effect. I hereby agree that this Agreement shall be effective and binding on my heirs, next of kin, executors, administrators, successors, representatives, assigns and/or transferees in the event of my death or incapacity.
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Agree
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