BSC - QC LTS Sign Up - Spring Session I

Swimmer's Name

First NameLast Name

Birth Date

MonthDayYear

Parent/Guardian Name

First NameLast Name

Cell Phone

Format: (000) 000-0000.

E-mail

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My Swimmer's Level

Has your swimmer ever participated in the Barracuda Swim Club Learn to Swim program?

I want to register for Session

Swimmer's School

Swimmer's Grade

Medical History and/or comments

Emergency Contact

First NameLast Name

Relationship to Swimmer

Emergency Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I, the undersigned parent or guardian, agree that I will not hold The Barracuda Swim Club, Queen's College, St. Andrew’s International School, and its coaches, instructors, members, associates and anyone acting on their behalf (singularly or together), responsible or liable to the above-mentioned swimmer, his or her heirs, executors, or representative (s) for any and all injury, damages, accidents, deaths, claims, actions or causes of action whatsoever connected the above-mentioned swimmer's person and or property or otherwise related to the said swimmer, arising or in connection with the Swimmer’s involvement in The Barracuda Swim Club’s Swimming program(s) or the facilities used in connection therewith. The undersigned further releases The Barracuda Swim Club, Queen's College, St. Andrew’s International School, Swim coaches, instructors, members, associates, and anyone acting on their behalf (singularly or together) from any claims whatsoever related to injuries that may result from any pre-existing condition or impairment that the swimmer may possess. The undersigned acknowledges that this release is given in advance to any injury to the above-mentioned swimmer and that includes any future injuries, damages and losses.

I acknowledge and accept that the above-mentioned swimmer is participating in this swimming program voluntarily and in full view and acknowledgement of all risks associated therewith and all its activities related thereto is voluntary and entirely at the above-mentioned swimmer’ own risk.

Signature