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REGISTRATION & WAIVER FORM
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Please complete this form and return PRIOR to your first lesson.
1. FAX to 561-245-8813
2. EMAIL to alyss@swimboca.com
Parent / Guardian / Self: Last ___________________________ First _______________________ Phone: 888-576-7946 (LRN-SWIM)
Address ____________________________________________ City _________________________ Email: Alyss@SwimBoca.com
State ______ Zip ______________ Home Phone _______________________ Mobile Phone _________________________
Email Address ___________________________________ Would you like to occasionally receive info by email? ____ YES ____ NO
How did you hear about Swim Boca? __________________________________ If referred, who referred you? ________________________
Date of Preferred Lesson Day & Time Are there any medical or learning Qty Length
Student Name related issues? Please Explain.
Birth (Please circle day and time) (circle) (circle)
6 20 min
M - T - W - Th - F - Sat | AM or PM 12 30 min
6 20 min
M - T - W - Th - F - Sat | AM or PM 12 30 min
6 20 min
M - T - W - Th - F - Sat | AM or PM 12 30 min
M - T - W - Th - F - Sat | AM or PM 6 20 min
12 30 min
I would like swim lessons to be held at: My Home or Community Pool Swim Boca’s Facility
Release of LIability
I , ___________________________________, the parent, legal guardian or student of (student(s) name) _________________________________
hereby give my permission for him/her/me to participate in the Swim Boca program. I agree to release and forever discharge Swim Boca, it’s
officers and employees from any and all liabilities, demands of claims for loss or damage resulting from any injury or damage which may be
sustained on the account of his/her/my participation in the program. I agree to abide by all of Swim Boca’s Policies.
REQUIRED FOR EVERY REGISTRANT: Please provide your credit card information to be kept on file at Swim Boca. A credit card is
required even if lessons are paid by check or cash. We accept Visa, Mastercard, Discover or Amex.
Name on card ________________________________________________ Visa Mastercard Discover Amex
Card # ___________ - ____________ - ___________ - _____________
3 Digit CVV ______ Expiration ______ / _______
Billing Address (if different from above) _____________________________________________________________________________
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WAIVER/RELEASE OF LIABILITY
PLEASE READ CAREFULLY BEFORE SIGNING.
THIS IS A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS.
The participant authorizes any representative of Swim Boca LLC to have the participant
treated in any medical emergency during their participation in private or semi-private
instruction at a facility used by Swim Boca, LLC or at the home/community pool of the
participant. Further, the participant and/or parent/guardian agrees to pay all costs associated
with medical care and transportation for the participant.
**IMPORTANT** I have noted on the back of this form any medical/health problems of which
the staff should be aware.
I HAVE CAREFULLY READ THE ABOVE LIABILITY RELEASE AND SIGN IT WITH FULL
KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE.
Signed: Date:
(Participant or Parent/Guardian)
Signed: Date:
(Participant or Parent/Guardian)
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