Private Swim Registration Form – Summer At Brentwood Commons

Private Swim - Student Information

Child First Name

Child Last Name

DOB

Parents First Name

Parents Last Name

Cell Number

Emailplease enter best email for us to reach you

Street Address

Town

State

Zip

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In order to better schedule our private lessons, please complete the information below. Once we have the competed form submitted, we will reach out to you with availability.

Please select

3-pack6-pack

Check here for private lessons1:1 with instructor

Check here for semi-private lessons2:1 with instructor

List other child in the lesson. Please submit a form for each child listed.

Check here group private lessons3 to 5 swimmers with instructor

List other children in the lesson. Please submit a form for each child listed.

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What is your goal for these lessons

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Please describe your childs comfort level in the water

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Please use this space to tell us anything else about your child that will help us develop a lesson plan

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Waiver

I, the duly authorized parent or guardian of the above-named Minor “Participant”, understand that the individual and/or group gymnastics and other physical exercise sessions, programs or activities conducted at Action Kids at Brentwood Commons, Inc. (hereafter “Action Kids”) may involve gymnastics, tumbling, fitness, trampoline, cheerleading, dance, ball sports, swimming and martial arts, as well as the use of exercise equipment, amenities and facilities owned and/or operated by Action Kids, its representatives or its contractors (collectively, the “Activities”). I, as the parent/guardian of the below-named Minor Participant, as a condition of authorizing their participation in such Activities do hereby agree to RELEASE and DEFEND, HOLD HARMLESS, and INDEMNIFY Action Kids, its shareholders, directors, officers, agents, faculty, volunteers, employees, representatives and contractors (hereinafter “the Releasees”) from all liability, claims, expenses, fees, fines, penalties, losses, suits, proceedings, actions and costs including attorneys’ fees and court costs, including personal injury and death, resulting from or arising out of their participation in the Activities whether caused by the alleged NEGLIGENCE of the Releasees or otherwise.I understand that the Activities in which my child or ward will be engaged may be dangerous, and I, as their parent or guardian, voluntarily choose to assume those dangers. I also recognize that by participating in the Activities my child or ward may experience injuries including, but not limited to, death or disability, and I willfully ASSUME THOSE RISKS. I agree that THIS LIABILITY RELEASE AGREEMENT IS BINDING ON THE PARTICIPANT AND THEIR PARENTS OR LEGAL GUARDIANS, PERSONAL REPRESENTATIVES, HEIRS, AND ASSIGNS.In the event of accident or emergency, I hereby authorize Action Kids to transport the Participant, or cause the Participant to be transported, to a medical facility for medical treatment and I agree to release, indemnify, defend and hold Action Kids and its representatives harmless with regard to same. I hereby agree to be fully and solely responsible for all medical expenses which may be incurred as a result of the Participant’s participation in the Activities.I understand that my child or ward’s participation in the Activities at Action Kids may be photographed, video recorded, audio recorded, or otherwise recorded. I acknowledge that Action Kids retains the right to use such photographs, video or audio recordings or any other recording of events for publicity, advertisement or any other legitimate purpose and I hereby consent to such use.

Confirmation

I, as the parent or guardian of the above-named Minor Participant, certify that I have carefully read the foregoing Liability Release Agreement and by my signature below, including any signature affixed in electronic format, consent to be bound by its terms. If I am not the parent or guardian of the below-named Minor Participant, by my signature below, I nevertheless agree to all of the terms and obligations in this Liability Release Agreement, as though I was the parent or guardian of the Minor Participant.

Electronic Signatureyour full name

Date

How to Sign Up for Private Swim Lessons

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