Please print
Name: ________________________ Date of Birth:__________________
Address:____________________________ Telephone:____________________

School:_____________________________ Grade (Fall 10):________________

Mother’s Name:______________________ Business Phone:________________
Father’s Name:_______________________ Business Phone:________________

Person to contact if parents cannot be reached:_______________________________
Relationship to child:__________________ Telephone:______________

Are there limiting factors which could restrict your child’s normal participation? Yes No
If yes, please specify:

Please tell us about your child’s swimming ability_______________________________

Does your child have any allergies that you are aware of? Yes No
If yes, please specify:

May ADAPT use photos in which your child appears? Yes No

I hereby pledge for myself, my heirs, executors or administrators, to waive and release all rights and claims for damages I may have against ADAPT. I also release this organization’s agents, assigns, or officials for any and all injuries suffered by my child.

Should my child be taken to the hospital for emergency purposes, I hereby grant permission to the attending physician and staff to treat my child, ____________ for anesthesia, medical, x-ray, and surgical procedures as may be deemed necessary or advisable.

I understand that in an emergency, an attempt will be made to communicate with me prior to use of this permission.
For hospital information ONLY:
Our doctor’s name ___________________________________ Doctor’s telephone:______________________
Medical insurance:_______________________ Policy #:______________________________ Subscriber:_____________________________

Signature of parent/guardian:______________________________ Date:________________

**Child's T-shirt size: __________________