Little Dipper Aquatic Center Waiver

All participants must have a signed waiver to be allowed to swim.


First Name/ MI/ Last Name: __________________________________________________________________________

First Name/ MI/ Last Name: __________________________________________________________________________

First Name/ MI/ Last Name: __________________________________________________________________________

Pool rental for families is for family members that all reside in the same household. As there is no lifeguard on duty during this private pool rental time, a responsible adult must accompany children at all times. For a child that does not swim the width of our pool (10 ft), they must be parentally guided or in a life jacket.  We ask that if you think your child needs a swim jacket to bring one from home, we do not supply swim jackets. All children who are under 3, regardless of level of potty training, or older children who are not fully potty trained, must wear a non disposable swim diaper. Currently, there are no pool toys provided, families are welcome to bring their own, understanding Little Dipper Aquatic Center is not responsible for any lost or damaged items brought into the center. During private pool rental, all regular safety rules apply, including but not limited to: no running in the center or around the pool, no diving or playing on platforms, no food, water bottles are allowed. Other facility amenities such as the changing rooms/showers/bathrooms by the pool will remain closed during COVID 19 safety guidelines, at which time  the family bathroom is the only facility allowed and open for use.

Please list any special needs, concerns or medical conditions:

PARENT(S)/GUARDIAN(S) NAME: ___________________________________________________________________

Address: __________________________________________________________________________

City, State Zip: __________________________________________________________________________

Home Phone Number:_____________________________

Cell Phone Number: ______________________________


Little Dipper Inc. RELEASE (Please Read and Sign Release Below)


1. Except for conditions that I have disclosed to Little Dipper Inc. to the best of my knowledge there are no physical or other conditions which will interfere with my child's participation. Safety rules are enforced. While our first priority is your child's safety, we must inform you that swimming is not risk free. As a participant or as a parent or legal guardian of a participant in a Little Dipper Inc. program, party,event, or open swim, I am fully aware that swimming can be strenuous, hazardous, and difficult. I acknowledge and freely accept the risks and hazards, including collisions, falls and risk of drowning, associated with the participation in swimming. I agree to hold Little Dipper Inc., Little Dipper Aquatic Center, its officers and agents free and harmless for any injuries or damages arising by reason of participation in this program.

2. I have read and agree to the policies listed here.

Parent/Guardian Name (please print)


Parent/Guardian Signature: __________________________Date:__________________