Summer Swim Program Online Fillable Registration Form 2017

If you have questions about this form, please view the PDF version available on the website for more information.

You can view the PDF form for more information by clicking here.

Parent Information

Child(ren) Information





YesNo

Champlain Children's Learning CenterCorner of Church St. and Main St.American LegionMooers Fire Department Complex Office


PLEASE SPECIFY AMERICAN RED CROSS CLASSIFICATION

(Write child(rens) name(s) next to the appropriate level) FOR AGES 5 AND UP!

Please Note: If the child(ren)'s swimming level is unknown DO NOT leave this area blank.

If this area is left blank they will not be able to be registered for this years’ program. If there are any questions regarding levels, feel free to contact Linda Fredette @ (518)297-6824 or [email protected]

Level 1: Has no swimming skills

Level 2: Has passed Level 1, can swim with kickboard/unassisted on front and back

Level 3: Can swim 5 yards Front Crawl and some Back Crawl in chest deep water, can swim some in deep water, and can swim on side

Level 4: Can swim Front and Back Crawl 15 yards, knows Butterfly motion and kick

Level 5: Can swim Front Crawl with rotary breathing 25 yds, Back Crawl 25 yds, Elementary Backstroke 15 yds, Breaststroke 15 yds, and can demonstrate Scissors kick

Level 6: Can swim 50 yds Front Crawl and Back Crawl, 25 yds Breaststroke, Sidestroke, Elementary Backstroke, and Butterfly

Form must be signed/dated in order for you child(ren) to be registered







By typing my name above I agree to the terms of this document and constitute it as signing this form.

Emergency Swimmer Record Form

** Please fill out all of the following and return to Linda Fredette by APRIL 8TH. You may use this form for up to four swimmers if all of the contact information is the same. If you have any questions or concerns please contact Linda Fredette @ [email protected] or (518) 297-6824.

Participant Information

First Name
Last Name
Birthdate
Sex




First Name
Last Name
Birthdate
Sex




First Name
Last Name
Birthdate
Sex




First Name
Last Name
Birthdate
Sex




Participant's Contact Information



Street Address
City
State
Zip







Primary Contact Information

Will be Contacted First In Case of an Emergency



Street Address
City
State
Zip







Secondary Contact Information



Street Address
City
State
Zip







Medical Information

Does the participant have any medical conditions the instructors should be aware of? (For example: diabetic, seizures, latex allergy, asthma, etc.)

YesNo









By typing my name above I agree to the terms of this document and constitute it as signing this form.

WAIVER AND RELEASE OF LIABILITY

DISCLAIMER: TOWN OF CHAMPLAIN/VILLAGES OF ROUSES POINT AND CHAMPLAIN SHALL NOT BE RESPONSIBLE FOR ANY INJURY (OR LOSS OF PROPERTY) TO ANY PERSON SUFFERED WHILE PLAYING, PRACTICING, OR IN ANY OTHER WAY INVOLVED IN THE TOWN PROGRAMS FOR ANY REASON WHATSOEVER, INCLUDING ORDINARY NEGLIGENCE ON THE PART OF TOWN OF CHAMPLAIN/VILLAGES OF ROUSES POINT AND CHAMPLAIN ITS AGENTS, OR EMPLOYEES.

In consideration of my child’s participation, I hereby release and covenant not-to-sue Town of Champlain, Villages of Rouses Point and Champlain, Town Board of the Town of Champlain, any of their employees, instructors, or agents, from any and all present and future claims resulting from ordinary negligence on the part of the Town or others for property damage, personal injury, arising as a result of my child’s engaging in or receiving instruction in Town activities or any activities incidental thereto, wherever, whenever, or however the same may occur. I hereby voluntarily waive any and all claims resulting from ordinary negligence, both present and future, that may be made by child, assigns, or me.

Further, I understand that these programs involve certain risks, including but not limited to, neck and spinal injuries injury to virtually all bones, joints, muscles, and internal organs, and that equipment provided for my child’s protection may be inadequate to prevent serious injury. I am allowing my child to voluntarily participate in this activity with knowledge of the danger involved and hereby agree to accept any and all inherent risks of property damage, or personal injury. In addition, I understand I may not always be there and in the event of an emergency, I hereby give permission for my child to be given emergency first aid treatment and or to be examined and treated at the nearest medical facility.

I further agree to indemnify and hold harmless Town of Champlain/Villages of Rouses Point and Champlain and others listed for any and all claims arising as a result of my child’s engaging in or receiving instruction in Town activities or any activities incidental thereto, wherever, whenever, or however the same may occur. I understand that this waiver is intended to be as broad and inclusive as permitted by the laws of New York and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be in New York.

I affirm that I am of legal age, the child’s legal guardian and am freely signing this agreement. I have read this form and fully understand that by signing this form, I am giving up legal rights and/or remedies which may be available to me for the ordinary negligence of the Town of Champlain, /Villages of Rouses Point and Champlain.









By typing my name above I agree to the terms of this document and constitute it as signing this form.