Registration Form May 5, 7, 12, and 14, 2017
Swimmer Information
For kids 4-12 years old
Fridays & Sundays May 5, 7, 12, and 14
30 minute classes between 3:30 and 5:30 pm
Deadline to submit an application is Monday May 1.
We will notify you of acceptance by Wednesday, May 3
Swimmer #1 Name: __________________________________ Date of Birth (MM/DD/YY): ______/______/______
Age ______
Gender: Male Female Previous swim lessons? Yes No If yes, how many years ago was the last lesson? 0 1 2 3+
Can swimmer #1 completely and comfortably submerge in water? Yes No Dog Paddle? Yes No Freestyle swim? Yes No
Swimmer #2 Name: __________________________________ Date of Birth (MM/DD/YY): ______/______/______
Age ______
Gender: Male Female Previous swim lessons? Yes No If yes, how many years ago was the last lesson? 0 1 2 3+
Can swimmer #2 completely and comfortably submerge in water? Yes No Dog Paddle? Yes No Freestyle swim? Yes No
Swimmer #3 Name: __________________________________ Date of Birth (MM/DD/YY): ______/______/______
Age ______
Gender: Male Female Previous swim lessons? Yes No If yes, how many years ago was the last lesson? 0 1 2 3+
Can swimmer #3 completely and comfortably submerge in water? Yes No Dog Paddle? Yes No Freestyle swim? Yes No
Time preference: 3:30pm 4:00pm 4:30pm Same time as another Family? _________________________________
Parent Contact
Parent #1 Name: ______________________________________________ Email Address: _______________________________
Ethnicity: __________________ Home Phone: (______) _______ - __________ Cell Phone: (______) _______ - __________
Mailing Address: _______________________________________ City, State, Zip: _______________________, CA 92_______
Parent #2 Name: ______________________________________________ Email Address: _______________________________
Ethnicity: __________________ Home Phone: (______) _______ - __________ Cell Phone: (______) _______ - __________
Mailing Address: _______________________________________ City, State, Zip: _______________________, CA 92_______
In event of an emergency, if I, the parent/guardian can’t be reached, I designate the authorized person below to act on my behalf:
Emergency Contact Name: ______________________________________________ Relationship to swimmer: ______________
Home Phone: (______) _______ - __________ Cell Phone: (______) _______ - __________
Do(es) the swimmer(s) have health insurance? Yes No If yes, medical insurance carrier/company name: ___________________
Medical
If no, I acknowledge and agree to pay any medical expenses incurred for my children. (circle yes) Yes
Year of last tetanus shot: Swimmer #1: _______________ Swimmer #2: _______________ Swimmer #3: _______________
Please list any injuries, medical conditions, handicaps, allergies or respiratory illnesses.
Swimmer #1
Swimmer #2
Swimmer #3
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Sponsored by the CAPS and HNP Offices of Loma Linda University
Address: 24945 Mound Street, Room 1402, Loma Linda, CA 92354
Phone: 909.651.5011 Web: www.caps.llu.edu
TIGERS Water Safety Visitor’s Pass Waiver Form
Name of First Swimmer: _____________________________________ Date of Birth: ______________________ Age: __________
Home Address: _______________________________________ City: ___________________ State: _____ Zip Code: __________
Phone Number: ______________________ Emergency Contact: ____________________________ Phone: __________________
Please list the names of all other registered swimmers and family members who will regularly attend TIGERS Water Safety activities.
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PLEASE READ THE FOLLOWING CAREFULLY
I understand that the activities available through Loma Linda University Drayson Center include, but are not limited to, basketball,
soccer, tennis, weightlifting, etc., and that these activities involve inherent risks of personal injury. I also understand that the use of
the University’s facilities shall be undertaken at my sole risk and that the University shall not be liable for any claims, demands, injuries, damages, actions, or causes of action whatsoever, to any person or property arising out of or connected with use of any of the
services or facilities of the University, its employees, or agents. By signing this Guest Pass Waiver, I am representing that I am in good
physical condition, and that I have no disability, impairment, or ailment that will prevent me from engaging in active or passive exercise. I acknowledge that the University has neither made claims as to medical results, nor suggested medical treatment.
I understand that part of the Drayson Center may be closed for certain events, and that no refunds or extension will be issued for
this time. I understand that breaking any of the Drayson Center policies at any time could result in cancellation of my Guest Pass
Waiver, that I will be asked to leave the premises, and that no refunds will be given.
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Signature of Parent
Date
Agreement and Release of Liability
1.
I DO HEREBY WAIVE, RELEASE, AND FOREVER DISCHARGE LOMA LINDA UNIVERSITY DRAYSON CENTER AND ITS OFFICERS,
AGENTS, EMPLOYEES, REPRESENTATIVES, EXECUTORS, AND ALL OTHERS FROM ANY AND ALL RESPONSIBILITIES OR LIABILTY FOR
INJURIES OR DAMAGES. (Initial Here:______)
2.
I HEREBY AGREE TO EXPRESSLY ASSUME AND ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH. (Initial Here:______)
3.
I DO HEREBY ASSUME ALL RESPONSIBILTY FOR MY PARTICIPATION AND ACTIVITIES, AND UTILIZATION OF EQUIPMENT AND
MACHINERY IN MY ACTIVITES. (Initial Here:______)
4.
TIGERS Water Safety Photo Release: I grant permission for my child’s photograph to be taken and used without their name
attached to publicize or promote this program. (Initial Here:______)
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Signature of Parent
Date