Non-Resident Activity Request

Non-Resident Activity Request
Name*

First NameLast Name
Email*
example@example.com
Phone*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GROUP SWIM LESSON REQUEST
PARTICIPANT (S) NAME
DATE OF BIRTH
FACILITY REQUESTED
SESSION (AM, PM, WKND)

AMPMWEEKEND
ACTIVITY NAME & NUMBER
PARTICIPANT (S) NAME
DATE OF BIRTH
FACILITY REQUESTED
SESSION (AM, PM, WKND)

AMPMWEEKEND
ACTIVITY NAME & NUMBER
PARTICIPANT (S) NAME
DATE OF BIRTH
FACILITY REQUESTED
SESSION (AM, PM, WKND)

AMPMWEEKEND
ACTIVITY NAME & NUMBER
Program/Event/Photograph Waiver In consideration of my (and/or my child's) participation in this activity, I hereby release and discharge the MCA, and its representatives, successors and assigns, from any and all liability arising from accident, injury, and illness that I (he/she) may suffer as a result of my (our) participation in this activity. I (we) also will follow the rules and regu-lations set by the MCA and above named parties. Parent or guardian must sign for anyone age 18 and under. I do hereby grant and give these groups the right to use my or my child's) photograph or image with or without my or my child’s name, both singly and in conjunction with other persons or objects and presentations, advertising, publicity and promotion relating thereto.
PARTY PAD REQUEST
FACILITY REQUESTED
Date

MonthDayYear
Date
PURPOSE OF EVENT
NUMBER OF GUESTS EXPECTED
Please verify that you are human*
Should be Empty:

GROUP SWIM LESSON REQUEST