 HICKORY
FOUNDATION YMCA SWIM LESSONS
For
your convenience, you may print out the form below, fill in the
information,
and either mail it or drop it by the YMCA. Please indicate the
session you are interested in. Session
Information can be seen by clicking HERE.
If you need help placing your
child, feel free to call Zach Finley at 324-2858 or email her at zachf@ymcacv.org.
|
Name: __________________________________________________________ |
M__ F__ |
| Address:
________________________________________________________ |
| City:
___________________ |
State:
________________ |
Zip:______________ |
| Phone
Number: _______________________ |
AGE: ________ |
DOB: _____________ |
| Level: _____________________ |
Time:
___________ |
YMCA
Member: Yes___ No___ |
| Mother's
Name: ________________________________________ |
| Father's
Name: _________________________________________ |
| Emergency
Contact:_______________________________ |
Phone:
__________________ |
| Allergies
or Medication: _______________________________________________________ |
|
Waiver
of Liability - Please read and sign |
I
fully assume and understand the risks of myself or
my child participating in the swim lesson program, including
death or injury due to falls, collisions
with other participants or spectators,
obstructions, sudden illness and
all other risks. I attest that myself or my child
is physically fit
to participate. I authorize program staff to
provide medical attention at my expense should
myself or my child appear in need. For injuries
myself or my child sustain, including
death, I agree to save and hold harmless the YMCA
of Catawba Valley, volunteers, program staff, suppliers, contractors, and anyone
else connected with the organization of this
program,
from any claim or lawsuit that may be brought at
any time by me, my family, estate, heirs or
assigns, arising from myself or my child's participation in this
program or the instruction received.
Waiver
For Publicity
I agree that images taken of myself or my child during
this program
may be used in any legal manner without payment to
me. I have read and understand the terms of this
document. I make this agreement and pay the
program
fee in exchange for the privilege of myself or my
child participating
under the conditions of the program. |
___________________________________
Signature (Parent/Guardian of under 18) |
________________________________
Date |
|
Please
mail and make checks payable to:
Hickory Foundation YMCA
701 1st Street NW
Hickory, NC 28601
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