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

Street Address Line 2

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Postal / Zip Code
Gender

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Cell Phone Number*
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Alt Phone Number
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Email*
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Does the participant have any medical conditions we should be aware of?*

YesNo
If yes, please specify:
Does the participant have any allergies?*

YesNo
If yes, please specify:
Is the participant currently taking any medication?*

YesNo
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.

AgreeDisagree
Annual Physical

Cancelof
How did you hear about this program?

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Are you a resident of Riviera Beach?

YesNo
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:*

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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:*

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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.
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THE CITY OF RIVIERA BEACH FIRE DEPARTMENT DROWNING PREVENTION SWIMMING LESSONS