Swimming Lesson Registration & Waiver

Participant Information

First

Last

Date of Birth

Age

Address

City/Town

State

Zip Code

Cell Phone Number

Email

Emergency Contact

First

Last

Cell Phone Number

Medical Information

Please list any medical conditions, allergies, or medications that the instructor should be aware of

Doctor's Name

Doctor's Phone

Authorization

Photo and Video Consent

I, the undersigned, grant permission to the City of La Cygne to take photographs and/or videos of the participant during swimming lessons for use in promotional materials, social media, and educational purposes.

Liability Disclaimer and Waiver of Claims

I, the undersigned participant (or parent/guardian if under 18), hereby acknowledge and agree that participation in swimming lessons involves inherent risks, including but not limited to drowning, slips, falls, and other injuries.

I voluntarily assume all such risks and release, indemnify, and hold harmless the instructors, staff, facility owners, and organizers of these swimming lessons from any and all liability, claims, or demands for personal injury, property damage, or loss arising from participation in this program, whether caused by negligence or otherwise.

I certify that I (or my child) am physically fit to participate in swimming lessons and have disclosed al relevant health information.

Signature

Name of Signer

Date