Wild Child Water Play Registration and Release Form
Adult Private Swim Lessons
Adult Name
_________________________________________________________________________________________
Address
_________________________________________________________________________________________
City
_________________________________________________________________________________________
Zip Code
_________________________________________________________________________________________
Home Phone ____________________________________ Work Phone _______________________________

E-mail Address_____________________________________________________________________________
(We only use e-mail address to send out class information and up-dates)

Circle the Day(s) of the Week

Monday
 Tuesday
 Wednesday
 Thursday
 Friday

Requested Time ______________________________________________________________________________

Requested Instructor __________________________________________________________________________

Circle the Cost per lesson

Single Lesson $ 60.00 per hour $ 40.00 per 1/2 hour

Package (5 lessons) 1 hour lessons $ 200.00 ($ 40.00 per hour)
Package (5 lessons) 1/2 hour lessons $ 150.00 ($ 30.00 per hour)

Make checks payable to Wild Child Water Play. Check Number: ________________ Amount: ________________

Mail this form and payment to: Dawn Urbanek, 142 Avenida Buena Ventura, San Clemente, CA 92672.

For more information visit our web site at http://www.wildchildwaterplay.com, or call Dawn Urbanek at (949) 361-3443.

WAIVER/RELEASE OF LIABILITY

PLEASE READ CAREFULLY BEFORE SIGNING
THIS IS A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS

I, ______________________________________________________________, the enrolled participant and/or the parent/guardian of the participant agree and understand that swimming is a HAZARDOUS activity. I recognize that there are risks inherent in the sport of swimming,including, but not limited to, paralyzing injuries and death.

The participant hereby agrees to participate in the WIld Child Water Play program and hereby agrees to indemnify and hold harmless Dawn Urbanek, an individual doing business as Wild Child Water Play, its coaches, officers, directors, agents and employees against any liability resulting from injury that may occur to the participant while participating in Wild Child Water Play. The participant agrees to Indemnify Dawn Urbanek, an individual doing business as Wild Child Water Play, for any damages incurred arising from any claims, demand, action or cause of action by the participant.

The participant authorizes any representative of Wild Child Water Play to have the participant treated in any medical emergency during their participation in Wild Child Water Play. Further, the participant and/or parent/guardian agrees to pay all costs associated with medical care and transportation for the participant.

I have noted on the back of this form any medical/health problems of which the staff should be aware.

I, HAVE CAREFULLY READ THE ABOVE LIABILITY RELEASE AND SIGN IT WITH FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE

Parent/Legal Guardian Signature: ____________________________________ Date: _______________

PHOTOGRAPHIC/VIDEO RELEASE

I permit the use of photography and/or video of my child for media promotions.

Parent/Legal Guardian Signature: ____________________________________ Date: _______________