Release of Hunter Mill Country Day School,
its Agents and Employees from Responsibility
for My Child's Participation in the
Inherently Dangerous Water and/or Swimming Activities
I,
___
(please print)
parent of _________________________________,
(please print)
hereby declare that I authorize Hunter Mill Country Day School to allow my child participate in
water and/or swimming activities, including field trips to go swimming at Oakmarr Recreation
Center.
I agree that in consideration for being permitted to participate in the inherently dangerous activity of
engaging in water and/or swimming activities, including but not limited to, water play on the
premises of Hunter Mill Country Day School and swimming activities at Oakmarr Recreation
Center, I agree for myself, my spouse, my child named above, legal representatives, heirs, and
assigns to release, waive, and discharge from all liability, Hunter Mill Country Day School, its
officers, employees, agents, and any land owners upon which the facilities of Hunter Mill Country
Day School operates, from all liability for any and all loss or damage and any claim or damages
resulting there from, on account of Injury to my child, even injury resulting in my child's death,
whether caused by the negligence of the releasees or otherwise while my child is engaged in any
water and/or swimming activities whatsoever, and any activities collateral to such activities while on
the premises of Hunter Mill Country Day School or under the supervision and care of employees of
Hunter Mill Country Day School. I assume full responsibility for the risk of bodily injury, death or
property damage whether due to the negligence of releasees or otherwise.
I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and
inclusive as possible as permitted under the law of the Commonwealth of Virginia.
I have knowingly executed this waiver of my rights to sue and agree to assume all risks.
This waiver shall remain valid unless expressly revoked by myself, in writing. If this waiver is so
revoked, I agree to refrain from any water and/or swimming activities whatsoever on the premises
or held elsewhere while under the control of Hunter Mill Country Day School.
Signed this __
day of
____
Signature of Releasor:
, year _____
______
Please print name here: ________
2021 Hunter Mill Road
___ .
___
Hunter Mill Country Day School
Vienna, VA 22181
703-281-4422
.
.
www.hmcds.com
Swim Assessment
This Assessment must be completed prior to your child participating in field trips to
Oakmarr Rec Center or other Rec Centers. Only 4 year olds and older that are fully potty
trained in the Grasshoppers, Frogs, Turtles, and Dragonfly classes may participate. (Please
complete one form for each child engaging in swimming activities)
Child’s Full Name:________________________________________________________
Child’s Date of Birth: _____________________________________________________
My child’s swimming ability, or lack thereof, is best described as:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________.
* Please describe your child’s swimming abilities and explain any special circumstances
regarding your child’s (in)ability to swim or special assistance needed.
 Excellent swimmer, able to swim in deep end of pool and use diving board
(swim test required by RecCenter);

Good Swimmer, able to swim in deep end of pool (swim test may be
required);
 Fair Swimmer, able to swim and tread water on his/her own in shallow
end/beach area of pool.

Poor Swimmer, not able to swim or tread water on his/her own (should not be
signed up for our Swim program – please speak w/Director immediately).
Parent’s Signature: _________________________________________________
Parent’s Name (print): _______________________________ Date: __________
2021 Hunter Mill Road
Hunter Mill Country Day School
Vienna, VA 22181
703-281-4422
www.hmcds.com