Ms. Sue's Swimming
Application and Release
Printable

Student Name___________________________________________________

 
Age ___________    Phone:  ________________________________________
 
Address _______________________________________________________
 
City ________________________________ State ________ Zip ___________
 
Email _________________________________________________________
 
Medical (If Pertinent)______________________________________________

______________________________________________________________


Adult Name if PAC Class___________________________________________


Session ________________    Date __________________________________
 
Time __________________    Level __________________________________


Additional Comments:  _____________________________________________

3 Easy Steps Required 
To Confirm your reservation please fill out.

1.
Application form
2. Signed release form 
 
3. Write check for $60 made out to Sue Opincar (Not Ms. Sue's Swimming) & mail to: 

    check # ________ for $______ (No credit cards)


Sue
Opincar
7857 S. Lamar Rd. 

Smyrna, TN 37167

One application per student required (print front & back if you wish) Separate check for each student not required.
Please note that your canceled check is your CONFIRMATION & receipt. We do not call to confirm & please note your calendars. 


No refunds without a two week notice of cancellation.  If you have any questions call 615-459-5124 

Release 

Name of Participant _______________________________________ Birth date __/__/____


Name of Participant _______________________________________ Birth date __/__/____


Name of Participant _______________________________________ Birth date __/__/____


Name of Participant _______________________________________ Birth date __/__/____



In consideration of being allowed to enter and participate in the swimming lessons provided by
Ms Sue’s Swimming located at 7857 S. Lamar Rd, Smyrna, TN 37167 the undersigned agrees as follows:


I am aware of that there is a risk of injury when participating in the swimming lessons provided by Ms Sue’s Swimming and the other activities near or in Sue Opincar’s pool, and I am aware that such injuries include, but are not limited to, bruises, cuts, scrapes, broken bones and even more serious injuries such as drowning or death.   I knowingly accept these risks, whether known or unknown, on behalf of myself and on behalf of my child(ren) or ward(s), including the risks that may arise from another participant’s negligence.   I understand that participation in this program is strictly voluntary, and I freely choose to participate and/or have freely chosen to allow my child(ren) or ward(s) participate. 

I, the undersigned, and my heirs and assigns, hereby release and hold harmless Ms Sue’s Swimming, Sue Opincar, and any other people officially connected with Ms Sue’s Swimming from any and all liability for injury from whatever source or death which might occur to myself, my child(ren), or my ward(s) while participating in any activities provided by Ms Sue’s Swimming or near or in Sue Opincar’s pool, including any injury caused by the negligence of Ms Sue’s Swimming, Sue Opincar, her employees or agents.   

I agree that I will be responsible for any and all medical costs I, my child(ren), or my ward(s) incur as a result of my/their participation in any activities provided by Ms Sue’s Swimming or which occur near or in Sue Opincar’s pool.   I further agree to reimburse Ms Sue’s Swimming, Sue Opincar, her employees, and agents for any legal fees, including court costs, that they may incur in the defense of any claim, cause or action, or demand waived under this Liability Waiver. In the event that litigation is brought against Ms Sue’s Swimming, Sue Opincar, her employees and agents for any reason, I agree to bring such action in Rutherford County, Tennessee.   I further agree that if any provision of this Agreement is found to be invalid or unenforceable, such provision shall be deleted and the remainder of this Agreement shall remain in full force and effect.


_____________________________________________________                  __/__/___
Signature of Parent or Guardian                                                        Date


_____________________________________________________                   __/__/___
Printed Name of Parent or Guardian                                                               Date



Coupon
Save 5.00

Good for your 3rd child or class enrolled in 2016. Coupon must accompany 3 applications.

 

Discount ID: 0517


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