ETSU CAMPUS RECREATION
BCPA SWIM LESSON REGISTRATION FORM
Kid’s Group lessons
Our Program:
-Biweekly lessons: Monday/Wednesday or Tuesday/Thursday from January 22nd- February 15th.
-Over the 4 week period there will be eight 30 minute sessions.
-Register from January 1st-January 15th at the BCPA Membership Desk (cash or check only).
-Maximum of 6 children per class (Instructor ratio 1:6); Min of 3 children in order for class to take place
-Email confirmation of lesson date/time will be emailed to below address the Sunday before classes start.
-NO MAKE UPS – Unless due to inclement weather or pool closing.
-For more info visit: www.etsu.edu/rec.
Registration Info
Today’s Date: ______
Swimmer’s Name: ______Age/DOB: ______
Parent’s Name: ______ETSU ID#:______
Email: ______Phone #:______
ETSU Department or if student year in school: ______
Payment (Check one)
ETSU Student……………………………………………………………...... $40
ETSU Faculty/Staff or LB/CSC/US………………………………...... $50
Non-ETSU………………………………………………………….….……….. $75
Lesson Levels (Check one; Ask front desk staff for lesson level descriptions)
Pre-School T/TH Classes Swim School M/W
Jellyfish:5:00pm-5:30pm Seal: 6:00pm-6:30pm
Sea Turtle: 5:30pm-6:00pm Dolphin: 6:30pm-7:00pm
FOR OFFICE USE ONLY
Date: ______Time: ______
Staff name: ______Payment: $40 / $50 / $75 (Circle one)
Staff: give patron one receipt, attach 2nd receipt to completed form & put in “Completed Group SL form” file
East Tennessee State University
Department of Campus Recreation - Basler Center for Physical Activity (BCPA)*
Swim Lesson Informed Consent/Assumption of Liability
Informed Consent:
I would like to participate in the ETSU Campus Recreation Swim Lesson Program. I am aware that there are risks and hazards which may arise through participation in this activity. These risks include but not limited to: drowning, near drowning, paralyzing injuries, brain injuries, and slipping on the pool deck. These activities may be of a hazardous nature and/or may include activities such as swimming, diving, a variety of strenuous exercises and physical activities. With the full understanding of the facts, I state that to the best of my knowledge, that I (or my son/daughter taking the lessons) has no medical, physical, or emotional health conditions, which would prevent his/her participation in the ETSU Swim Lesson program.
Assumption of Liability (participants 18 years old and up):
I willingly and knowingly assume for myself, my heirs, family members, executive administrators and assigns all risk of physical and emotional injury which may occur during or after participating in any aspect of the program and hereby agree to hold the State of Tennessee, The Tennessee Board of Regents, East Tennessee State University, its employees, instructors, facilitators, agents and volunteers harmless for any liability arising out of my participation in the program. Should ETSU or anyone acting on behalf be required to incur attorneys fees and costs to enforce this agreement, I agree to indemnify (to assume the responsibility for payment of damages to someone else) and hold ETSU harmless for all such fees and costs. This release does not, however, apply to physical injury or emotional harm caused by negligence or willful misconduct of ETSU, its employees, instructors, facilitators, and agents.
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Participants printed name
______
Participants signature (do not sign if under 18) Date
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***FOR PARTICIPANTS UNDER THE AGE OF 18 ***
The below named participant, a minor for whom I am the parent or legal guardian, has my permission to participate in the ETSU Campus Recreation Swim Lesson Program. I have read the informed consent and on behalf of myself and my minor daughter/son, I release the State of Tennessee, The Tennessee Board of Regents, East Tennessee State University, its employees, instructors, facilitators, agents and volunteers from any and all liability in connection with my minor daughter/son’s participation in this activity. I understand that this release covers any and all claims again East Tennessee State University (or any of those mentioned above), including claims of negligence. I agree that this release binds me, my family, estate, and/or heirs.
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Print participant’s/child’s name Parent/Guardian printed name
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Parent/Guardian signature Date