ETSU CAMPUS RECREATION

BASLER CENTER PHYSICAL ACTIVITY

PRIVATE SWIM LESSON REGISTRATION FORM

Today’s Date:______

Swimmer’s name:______Age:______

Swimmer’s current level & desired goal(s) from lessons: ______

______

Parent/Guardian Name (if applicable):______

E#:______Email:______

Cell Phone:______Work or Home Phone: ______

ETSU Department or if student year in school:______

6 lessons in a package (Circle one): Students: $60 Fac./Staff: $70

Please let us know your availability to take 30 min. lessons (circle all that apply and at least 3 options):

Mon 6:15-8:15am Tue 6:15-8:15am Wed 6:15-8:15am Thu 6:15-8:15am Fri 6:15-8:15am

Mon 11am-1pm Tue 11am-1pm Wed 11am-1pm Thu 11am-1pm Fri 11am-1pm

Mon 4-7:30pm Tue 4-7:30pm Wed 4-7:30pm Thu 4-7:30pm Fri 4-7:30pm

Sat 10am-2pm Sun 4-7pm

*Lessons are for ages 3 years and up.

*Lesson date/time will depend on instructor availability

*Email confirmation of lesson date/time will be sent to address above within 3-5 business days

*Both Instructor and Participant are required to give a 24 hour notice if a class is canceled.

For more info visit: www.etsu.edu/rec

FOR OFFICE USE ONLY

Date: ______Time: ______

ID Checked: (Student or Fac./Staff) ______Staff name: ______

Swim Lesson (circle one): Cash OR Check #______

Staff: give patron receipt, put registration form in bottom drawer of filing cabinet in completed private swim lesson folder.

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.

______

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.

______

Print participant’s/child’s name Parent/Guardian printed name

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Parent/Guardian signature Date