Seaside Aquatic Swimming Club Waiver Form

Fields marked with an * are required

Student's Name

First

Last

Student's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth

Gender

Male
Female

Parent's/Guardian's Name

First

Last

Home Phone

Mobile Phone

Parent's/Guardian's Email

Emergency Contact Name

First

Last

Relationship

Emergency Contact's Home Phone

Emergency Contact's Mobile Phone

Does the student have any allergies, chronic illnesses, or medical conditions? If yes, please describe

Yes
No

Please describe all medical conditions if yes was chosen above.

Is the student prescribed an inhaler and/or medication? If yes, please explain any instructions

Yes
No

If yes, please explain any instructions regarding the administration of such.

I hereby give my approval for my child's/ward's participation in any and all activities prepared by Seaside Aquatic Swimming Club. In exchange for the child's/ward's acceptance, I

Parent's/Guardian's Name

First

Last

assume all risk and hazards incidental to the conduct of the activities, its respective instructors, counselors, and representatives from any and all liability for injuries to said child/ward arising out of travelling to, participating in, or returning from selected swimming sessions, In case of injury to said child/ward, I hereby waive all claims against, including all coaches and affiliates, all participants, and, if applicable, owners.

Parent's/Guardian's Name

First

Last

St. Luke's Academy

Inspiring Excellence

Seaside Aquatic Swimming Club

Registration Form

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