Course Registration Form

Name *
Name
Mobile Phone *
Mobile Phone
"All" is appropriate, as is "None". If you just need certain things, please specify. (a watersport helmet is necessary for most courses.)
If registering for more than one course, please submit a separate form for each course.
PARTICIPANT RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT: In consideration of being allowed to participate in any way in the program, related events and activities, I the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death. 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation. 3. I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately. *
The remaining questions ONLY NEED TO BE ANSWERED ONCE per season. If you have already done so, and your health is unchanged, you may skip to the end and SUBMIT FORM.
Confidential Medical Information
Only necessary if we are bringing equipment for you.
Do you or have you had any of the following medical conditions??
Please check all that apply. (answers are confidential, and strictly for use by instructional staff)
If there are any other conditions that may affect your participation in this course, please include those as well.
When you walk a mile (15-20 min. pace) do you experience shortness of breath, chest pain, or other discomfort?
How comfortable are you swimming with your face in the water?
(please provide name and phone number of someone to call in case of a medical emergency)