APPLICATION FOR TYC SWIM PROGRAM

NAME ______________________________ BIRTH DATE____/____/____

AGE________

NAME_______________________________ BIRTH DATE____/____/____

AGE________

PARENT’S NAME_________________________________________

TELEPHONE NUMBER_____________________________________

PARENT’S ADDRESS__________________________________________________________________

I/we the undersigned, being the parent/legal guardian of the above children, in consideration of the acceptance of our child/ward as a participant in the TYC Swim Program, do hereby acknowledge that participation in said program poses certain inherent risks which cannot be avoided and acknowledge that we are accepting the risks.

I/We further release the TIVERTON YACHT CLUB, its Board of Directors, and Swim program committee, their agents, and employees from any and all claims for injury, damages, or death arising as a result of our child/ward’s participation in this program.

I/We further accept responsibility for the actions of our child/ward while attending the Swim Program, and will be responsible to the TIVERTON YACHT CLUB for any damages or harm caused by our child/ward to the property or person of another.

________________________________

PARENT OR LEGAL GUARDIAN

WITNESS _____________________________________DATE_________________________

Payment is due the first week of classes. Send check and registration form to:

TIVERTON YACHT CLUB SWIM PROGRAM

C/O Ken Kiley, 40 Penny Pond Road, Tiverton, RI 02878

or contact Amy Texeira directly at 401-624-6116.

for office use:

CHECK NO.________________ DATE___________________