DMSF Group Swimming Lessons Waiver

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Swimmer Name *

Swimmer DOB *

YYYY

Swimmer Age *

Parent/Guardian Name: *

Parent/Guardian Address and Contact Information *

Emergency Contact/Phone Number *

Insurance Carrier/Phone Number *

Physician/Phone Number *

Please select the level which best fits your student’s swimming experience and ability. We will assess the swimmer during the first lesson and move kids to a different level, if necessary. *

Level 1: Limited experience in the pool. Working on bobs, blowing bubbles, floating front and back, freestyle and backstroke for 5 yards

Level 2: Working on freestyle and back stroke for 10 yards, kicking and streamline.

Level 3: Working on Freestyle and back for 15-20 yards, dolphin kick, sitting and kneeling dives.

Level 4: Working on Freestyle and Back for 25 yards, streamline kicks, butterfly, breaststroke, standing dives

Medical Release Waiver: I certify that I am the parent or legal guardian for my child(ren). I hereby give my permission for any supervisor, coach, swim lesson instructor or other team administrator associated with the Des Moines Swimming Federation to seek and give appropriate medical attention for our child(ren) in the event of accident, injury, illness. I will be responsible for any and all costs associated with any necessary medical attention and/or treatment. I hereby waive, release and forever discharge Des Moines Swimming Federation and associated supervisor, coach, swim lesson instructor or other team administrator from all rights and claims for damages, injury, loss to person or property which may be sustained or occur during participation in Des Moines Swimming Federation activities, whether or not damages or loss is due to negligence. I hereby acknowledge that my children is (are) physically fit and capable of participation in all Swim Lesson activities. *

Check this box if you agree to the terms of the Medical Release Waiver

Check this box if you DO NOT agree to the terms of the Medical Release Waiver

Required

Liability Waiver: By registering my child(ren) with the Des Moines Swimming Federation Swim Lesson Program, I agree to participate (or allow my child(ren) and family members to participate) in the Des Moines Swimming Federation Swim Lesson Program, and hereby release Des Moines Swimming Federation, its directors, officers, agents, coaches, and employees from liability for any injury that might occur to myself (or to my child(ren) and family members) while participating in the Des Moines Swimming Federation Swim Lesson Program. For and in consideration of entrance onto the premises, I agree to release Des Moines Swimming Federation and its owners, officers, operators, agents and employees from, and waive, any and all claims and liability arising out of services they provide and/or use of their facility, including but not limited to personal injuries or damages arising from their ordinary negligence. This release and waiver apply to myself and any minor child I bring onto the premises. I agree to indemnify and hold harmless the above mentioned organizations and/or individuals, their agents and/or employees, against any and all liability for personal injury, including injuries resulting in death to me, my child(ren) and/or other family members, or damage to my property, the property to my child(ren) and/or other family members, or both, while I (or my child(ren) or family members) participating in the Des Moines Swimming Federation Swim Lesson Program. *

Check this box if you agree to the terms of the Medical Release Waiver

Check this box if you DO NOT agree to the terms of the Medical Release Waiver

Required

Parent/Guardian Signature and Date *

Submit

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