Swim Voucher Registration Form

🏊Pediatric Survival Swim Voucher Registration Form🏊‍♀️

Student First and last name

Gender

Male

Female

Parent first and last name

Child’s Birthday

Month

Day

Year

Swim voucher number and county voucher was given with:

Phone

Address

Parent occupation

Who all will be bringing child to lessons? Please add phone number.

Health Information We ask that you try and be as accurate as possible. We never share

information about our clients. This information is used only to provide accurate information for

the instructor. These results may potentially alter the length of your child's program. We see

many clients who receive multiple health services. We need to make sure we are not interfering

with any medical professionals, especially therapies.

Pediatrician name and number:

Has this child ever been referred to a specialist of any kind? If YES is selected, please provide details below.:

Yes

Specialist information and reasoning. Does your child still receive these services?

Has this child ever seen a therapist (this includes physical therapist)? If YES is selected, please provide details below

Yes

Please specify if checked YES. Does this child still receive these services?:

Do you have any additional information or requests not already mentioned on this form?

Participation Agreement:

I am the _______ Parent /Guardian of this student. :

Waiver

To participate in aquatic activity. My child is in good health and physical condition and is not suffering

from any condition that would prevent him/her from engaging in this activity.

Please read carefully and be aware that in registering your minor child for participation in this

program, you will be waiving and releasing all claims for injuries you or your child might sustain as a

result of participation in any class or activity conducted by Pediatric Survival Swim, Allison Hogue,

and all Independent Swim Instructors working under the Pediatric Survival Swim name. As a

parent/guardian of a participant in Pediatric Survival Swim/ Allison Hogue's swim lessons, All

Independent Swim Instructors working under the Pediatric Survival Swim name, I recognize and

acknowledge that there are certain risks associated with these lessons. I agree to indemnify and hold

Pediatric Survival Swim Any Independent Swim Instructor working under the Pediatric Survival Swim

name, Allison Hogue, Homeowners, harmless from any liability resulting from the use of premises and

waive and relinquish all claims against Pediatric Survival Swim, Allison Hogue, and the pool owners

that I or my minor child/children (swimming or not) may sustain while on the property or personal

residence or as a result of participating in any form of swimming program offered by Pediatric Survival

Swim, Allison Hogue, Allison Hogue swim lessons, any Independent Instructor working under

Pediatric Survival Swim. I have read all material and fully understand the above waiver and release of

all claims, and it shall not be modified orally.

This is a checkbox.

Sign

Please type full legal name

Date

Month

Day

Year

Policy Regarding Firearms and Weapons

For the safety and security of all children, families, and staff, our facilities, pool premises, and surrounding property are designated as a weapons-free zone.

Firearms, ammunition, or any other weapons are strictly prohibited and are not permitted on the premises at any time, regardless of any state or local laws allowing unlicensed carrying or firearms in public spaces. This policy is non-negotiable and is implemented to maintain the most secure and developmentally appropriate environment possible for our students, who are primarily young children learning survival skills.

Any violation of this policy will result in immediate termination of lessons and access to our facility, without a refund.

I have read the Firearms and Weapons Policy.

Photo/Videography

Photos and videos (many of which are underwater,) may be taken in conjunction with lessons by your

instructor. Video use is for training and review to improve your child's lessons. I

(parent/grandparent/legal guardian) understand that if you agree, video/picture media may be used for

informational advertising purposes. Whenever possible those photos and videos will be shared with

parents. If you do NOT wish for any pictures or videos to be taken of your child, please write NO in the

signature. We respect your right to privacy.

Sign

I agree to the terms &

conditions:

Important Note on Lesson Progression: I understand that eight lessons may not be sufficient for my child to achieve full mastery of Survival Swim skills and that continued lessons are recommended.

I understand that my child will need continuous, vigilant supervision in and around the water, even after completing the eight-lessons voucher program.

Signature

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