New Student - Swimming Pool Waiver Release Form

Student(s) Name*

Does your child have any medical or health concerns?*

NoYes, please explain.

Does your child have any allergies?*

NoYes, please explain.

Does your child have a fear of water?*

NoYes, please explain.

Is your child comfortable in or around a pool?*

NoYes

Does your child know how to swim (at any level)?*

NoYes, please explain.

Does your child know how to tread water?*

NoYes

Does your child know how to float?*

NoYes

Does your child understand the importance of not diving into shallow water?*

NoYes

Is your child able to listen and follow directions?*

NoYes

Is there anything else you would like us to know about your child?

Emergency Point of Contact

First NameLast Name

Emergency POC Phone Number

Please enter a valid phone number.

**LIABILITY WAIVER AND RELEASE**

By signing this form, I, the undersigned parent or guardian, do hereby grant permission for my child, named above, to participate in the swimming lessons conducted by Ruff Seas Swimming School. I understand and acknowledge that there are risks and hazards associated with the activities involved in this program, including the potential for serious personal injury. I voluntarily accept these risks on behalf of my child.

I hereby release, discharge, and agree not to sue Ruff Seas Swimming School, its employees, officers, directors, agents, and volunteers, for any injury, death, or damage to or loss of personal property arising out of, or in connection with, my child’s participation in the swimming lessons from whatever cause, including the active or passive negligence of Ruff Seas Swimming School, its employees, officers, directors, agents, and volunteers, to the fullest extent permitted by law.

Parent/Guardian Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signature (Type your full name to act as your signature and acknowledgement of the Liability Waiver and Release statement above.)*

Date Signed*

Date

Signature

Date Signed

Date

My Products*

Registration Fee$10 registration fee per child

$10.00 Quantity
Item subtotal:$0.00

Total

$0.00

Credit Card

Ruff Seas - Swim School

Credit Card