Drowning Prevention Swim Lessons

THE CITY OF RIVIERA BEACH FIRE DEPARTMENT DROWNING PREVENTION SWIMMING LESSONS

June 16th - 20th 2025
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Address

Street Address

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CityState / Province

Postal / Zip Code
Gender
Cell Phone Number
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Alt Phone Number
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Email
example@example.com
Does the participant have any medical conditions we should be aware of?
If yes, please specify:
Does the participant have any allergies?
If yes, please specify:
Is the participant currently taking any medication?
If yes, please list:
I have/my child(ren) has received a physical examination by a licensed health care provider within the last two years and have been foundphysically capable of participating in Recreation Programs with the City of Riviera Beach.
Annual Physical

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How did you hear about this program?
Are you a resident of Riviera Beach?
Media Release Waiver: I hereby grant permission to the City of Riviera Beach Fire Department to use photographs, video recordings, or other media of myself or my child(ren) taken during participation in the recreation program(s). These may be used for promotional purposes including, but not limited to, brochures, social media, or the City's website, without compensation.
Participant Initials:
Transportation Waiver: I hereby give permission for the City of Riviera Beach Fire Department to provide transportation for myself or my child(ren) to and from program activities as needed. I understand that the City, its employees, and any third-party transportation providers shall not be held liable for any incidents, accidents, or injuries that may occur during transportation to or from activities.
Participant Initials:
Waiver and Consent: I, the undersigned, hereby release and hold harmless the City of Riviera Beach, a municipal corporation, its officers, agents, and employees from any and all liability, claims, demands, and causes of action arising from participation in the Fire Department program(s). I also authorize the staff to secure emergency medical services for the participant when deemed necessary.
Participant Initials:
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THE CITY OF RIVIERA BEACH FIRE DEPARTMENT DROWNING PREVENTION SWIMMING LESSONS