Little Dipper Aquatic Center Waiver

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

PARTICIPANT(S) INFORMATION

First Name/ MI/ Last Name: __________________________________________________________________________

First Name/ MI/ Last Name: __________________________________________________________________________

First Name/ MI/ Last Name: __________________________________________________________________________

A responsible adult must accompany children that cannot safely swim the width of our pool (10 ft). Unless a parent or guardian is with their child in the water, all participants will be given a brief swim test to determine whether or not a lifejacket must be worn. 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.

Please list any special needs, concerns or medical conditions:

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

Address: __________________________________________________________________________

City, State Zip: __________________________________________________________________________

Home Phone Number:_____________________________

Cell Phone Number: ______________________________

E-mail:_____________________________________________________________________

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

PERMISSION TO PARTICIPATE/LEGAL RELEASE:

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:__________________