SWIM LESSON REGISTRATION FORM
Student’s Last Name Our Redeemer Church
SWIM LESSON REGISTRATION FORM Mother’s Name Father’s Name Address City/Zip Language Spoken at Home: Participant’s Name Last, First
Mother’s Cell Father’s Cell Home Number Email
Sex M/F
Birthdate Age MM/DD/YY
Level
Circle Session/Enter Schedule Time 1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4 Total
RELEASE OF LIABILITY Should any illness or accident to him/her occur during Swim Activities for the period June 26th through August 25th, 2017, my consent is given to any licensed physician, to administer such treatment as the physician shall think the existing emergency requires. I hereby further relieve Our Redeemer Lutheran Church, 12301 Magnolia Street, Garden Grove, California and its Swim Staff, Pastors, Preschool Staff, Church Council and personnel of any liability due to accidents, injuries, or property loss that might occur during the swim lessons for swim season 2017. ** I further give my permission to allow the staff to photograph my child for the purpose of sharing with families on ‘Shutterfly,’ and publicizing our program in brochures and on the church website. Signature of Parent/Guardian MEDICAL HISTORY Medical Insurance Company Medical ID# Please list any Medical conditions or special accommodations your child may need. Name
OFFICE USE ONLY: PAID $ PAID $ PAID $ PAID $
Medical Condition/Special Accommodations
CASH/CHECK# CASH/CHECK# CASH/CHECK# CASH/CHECK#
DATE REC’D DATE REC’D DATE REC’D DATE REC’D
INITIALS INITIALS INITIALS INITIALS
Total
Student’s Last Name
REFUND POLICY FOR SWIM LESSONS: Session One (June 26 - July 7): Full refund will be given on or before June 19. 50% refund will be given after June 19 and before June 22. After June 22, no refund will be given.
Session Two (July 10 - July 21): Full refund will be given on or before July 3. 50% refund will be given after July 3 and before July 6. After July 6, no refund will be given.
Session Three (July 31 – Aug. 11) Full refund will be given on or before July 24. 50% refund will be given after July 24 and before July 27. After July 27, no refund will be given.
Session Four (Aug. 14 - Aug. 25) Full refund will be given on or before Aug. 7. 50% refund will be given after Aug. 7 and before Aug. 10. After Aug. 10, no refund will be given. *No refunds or makeup days for illness, vacation, holiday or inclement weather* Signature: _______________________________________ Date: _______________
SWIM LESSON REGISTRATION FORM Mother’s Name Father’s Name Address City/Zip Language Spoken at Home: Participant’s Name Last, First
Mother’s Cell Father’s Cell Home Number Email
Sex M/F
Birthdate Age MM/DD/YY
Level
Circle Session/Enter Schedule Time 1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4 Total
RELEASE OF LIABILITY Should any illness or accident to him/her occur during Swim Activities for the period June 26th through August 25th, 2017, my consent is given to any licensed physician, to administer such treatment as the physician shall think the existing emergency requires. I hereby further relieve Our Redeemer Lutheran Church, 12301 Magnolia Street, Garden Grove, California and its Swim Staff, Pastors, Preschool Staff, Church Council and personnel of any liability due to accidents, injuries, or property loss that might occur during the swim lessons for swim season 2017. ** I further give my permission to allow the staff to photograph my child for the purpose of sharing with families on ‘Shutterfly,’ and publicizing our program in brochures and on the church website. Signature of Parent/Guardian MEDICAL HISTORY Medical Insurance Company Medical ID# Please list any Medical conditions or special accommodations your child may need. Name
OFFICE USE ONLY: PAID $ PAID $ PAID $ PAID $
Medical Condition/Special Accommodations
CASH/CHECK# CASH/CHECK# CASH/CHECK# CASH/CHECK#
DATE REC’D DATE REC’D DATE REC’D DATE REC’D
INITIALS INITIALS INITIALS INITIALS
Total
Student’s Last Name
REFUND POLICY FOR SWIM LESSONS: Session One (June 26 - July 7): Full refund will be given on or before June 19. 50% refund will be given after June 19 and before June 22. After June 22, no refund will be given.
Session Two (July 10 - July 21): Full refund will be given on or before July 3. 50% refund will be given after July 3 and before July 6. After July 6, no refund will be given.
Session Three (July 31 – Aug. 11) Full refund will be given on or before July 24. 50% refund will be given after July 24 and before July 27. After July 27, no refund will be given.
Session Four (Aug. 14 - Aug. 25) Full refund will be given on or before Aug. 7. 50% refund will be given after Aug. 7 and before Aug. 10. After Aug. 10, no refund will be given. *No refunds or makeup days for illness, vacation, holiday or inclement weather* Signature: _______________________________________ Date: _______________
