100BMGWDC x Diversity in Aquatics #2 Event

Water Safety Registration Questionnaire

Register for the Maryland Water Safety Festival and provide important participant and safety information.
Maryland Student Requirement:

The STATE OF MARYLAND provides annual grants to qualified non-profit organizations that provide enriching educational programs to Maryland students. Eligible programs provide learning experiences that align with the State’s curricular and educational priorities and cannot be replicated in the classroom.
Are you a Maryland Resident/Student?
Parent/Guardian First Name
Parent/Guardian Last Name
Email Address
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Street Address
City
STATE
Zip Code
Emergency/Alternate Contact Name
Relationship to Participant
Emergency/Alternate Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2nd Emergency/Alternate Contact Name
2nd Emergency/Alternate Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Participant First Name
Participant Last Name
Participant Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant Age
Participant School
How did you hear about the event?

Other
Participant Gender
Swimming Ability
Medical Conditions / Allergies / Accommodations (Write N/A if non)
Interested in Child or Adult Learn-to-Swim Classes?
If yes, Participant Name
If yes, Participant Age
Programs You Would Like to Learn More About
Photo and Media Release
Liability Waiver Agreement (Type Your Name to Agree)
Parent/Guardian Initials (Consent)
Parent/Guardian Initials (Transportation Waiver- Acknowledges that parent/guardian is responsible for pick-up and drop-off)
Consent Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Maryland Student Requirement:

By clicking submit you are confirming that you are a Maryland Parent/Student registering for this program.
By signing this agreement the parent/guardian certififies that they are the legal guardian of the participant and that they agree to all terms and have answered each question correctly.
Signature
Should be Empty:

Water Safety Registration Questionnaire

Maryland Student Requirement:

Maryland Student Requirement: