Swim Lessons signup

Date

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Name

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DERC Member

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Upload

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Date of Birth

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Address

Address Line 1

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City

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State

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Postal Code

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Mark day(s) attending practice:

Week 1: June 15— June 18, 11am-Noon

Week 2: June 29 — July 2, 11am-Noon

Week 3: July 13 — July 16, 11am-Noon

Week 4: July 27 -July 30, 11am-Noon

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Please list any medication, illnesses, allergies, or any medical related information you want us to know or be aware of. (Participants with fever or infections are not allowed in the water.):

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Parent’s Name:

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Email:

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Home Number

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Cell Number

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Do you receive text messages?

Yes

No

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Add Another Parent:

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Parent’s Name:

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Email

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Home Number

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Cell Number

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Do you receive text messages?

Yes

No

Contact 1:

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Relationship of child:

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Cell or Daytime Phone:

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Contact 2:

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Relationship of child:

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Cell or Daytime Phone:

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Signature

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Date

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Waiver: I certify that my child is in good health, and I agree to permit my child to participate in this summer program. I further agree that, should my child be injured while participating in this program, I will not make any claim against DERC and its representative/employees relating thereto. In the event of an emergency and I cannot be reached, I give permission to the physician, the adult leader in charge or coach to hospitalize or secure necessary treatment for my child. I permit the DERC to use images and audio/video recordings of my child as a program participant in promotional material.espond to my inquiry.

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Medical Information

Contact Information

Emergency Contact Information

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