2021 MR SSC Summer Mad Dash Meet Waiver Form - INFORMED CONSENT/HOLD HARMLESS WAIVER FOR PARTICIPATION
MEET DATE: June 6, 2021
Sachem Swim Club of LI, Swim Meet @ Nassau County Aquatic Center
PURPOSE AND EXPLANATION OF PROCEDURE
I hereby consent to voluntarily engage in the Swim Meet at Nassau County Aquatic Center on June 6, 2021
I have been informed that during my participation in the above described Aquatic program, I will be asked to stop if any symptoms such as fatigue, shortness of breath, chest discomfort or similar occurrences appear. At this point, I have been advised that it is my complete right to decrease or stop exercise and that it is my obligation to inform the Instructor/Program/Coach personnel of my symptoms, should they develop.
It is my understanding and I have been informed that there exists the remote possibility that during exercise and or competition of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to injurers to the muscles, ligaments, tendons, and joints of the body. Every effort will be made to minimize these occurrences by proper staff assessment of my condition before each session, staff supervision during exercise and by my own careful control of exercise efforts. I fully understand the risks associated with exercise, including the risk of bodily injury, heat attack, stroke or even death, but knowing these risks, it is my desire to participate as herein indicated.
We (I), the undersigned, agree to release, hold harmless, and indemnify the Sachem Swim Club of Long Island, Metropolitan Swimming, USA Swimming, Nassau County, Nassau County Aquatic Center, its trustees, officers, agents, representatives and employees from and against any and all liability, lawsuits, claims, damages, or claims of injuries to my (our) child or children, including any negligent act or omission by the named above or its agents, representatives or employees, which are not the result of gross negligence, intentional neglect, or willful or wanton conduct by the named above.
We have put in place preventative measures, as required by the CDC and the State of New York, to reduce the spread of COVID-19 and other communicable diseases; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19 or other communicable disease. Further, participating in this swim meet could increase your risk and your child(ren)’s risk of contracting COVID-19 or other communicable disease. I am aware of risks as described by the current outbreak of COVID-19, and agree to release and hold harmless the Sachem Swim Club of Long Island, Metropolitan Swimming, USA Swimming, Nassau County, Nassau County Aquatic Center, its trustees, officers, agents, representatives and employees from and against any and all liability lawsuits, claims or damages arising from the transmission of any communicable diseases, including but not limited to COVID-19(SARS-COV2), before, during or after participation in this swim meet on June 6, 2021.
A SEPARATE FORM MUST BE FILLED OUT FOR EACH INDIVIDUAL, NO MULTIPLE PEOPLE RESPONSES
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Parent/Legal Guardian Full Name
Parent/Guardian Contact Number
Name of Swimmer/Official/Participant
SSC - Sachem Swim Club
CSDC - Connetquot Swim and Diving Club
EHY - East Hampton YMCA
FA - Farmingdale Aquatics
HAA - Hauppauge Athletic Association
HYB - Huntington YMCA
IA - Islanders Aquatics
Saw Mill Storm
TRI - Trident Aquatic Club
TS - Team Suffolk/HHH
TVSC - Three Village Swim Club
WAVE - Waverunners
WEST - Westchester Aquatic Club
WISC - West Islip Swim Club
Emergency Contact Name/Phone
I agree to above terms and conditions
A copy of your responses will be emailed to the address you provided.
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