Consent and Release

  • Family Name

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  • Liability Release

  • By clicking "I agree" at the end of this form, I have agreed to the consent and release rules for Valley Swim Club.
    Liability Release. I agree to assume and accept, on behalf of myself, each family member listed above and any guest I bring (“My Family”), all risks and hazards of activities conducted by, on property of, or affiliated with Valley Swim Club, including swimming and pool use, on-site programs, recreational and sport activities, and transportation to and from such activities (“Swim Club Activities”). I understand that participation in Swim Club Activities may result in injury to myself or members of My Family, possibly including serious personal injury, permanent disability, or even death. I understand that participation by My Family members in Swim Club Activities is a privilege and that execution of this document is required by Valley Swim Club as a condition for participating in any Swim Club Activities. I agree that I will not hold liable Valley Swim Club, its officers, employees, members, or volunteers, (together, “Released Parties”), for any damages, losses, or injuries to any members of My Family. I release and indemnify the Released Parties from any medical expenses, claims, losses, damages, or injuries (together “Claims”) which any of My Family members may incur related to Swim Club Activities, whether such Claims were foreseeable or unforeseeable, or caused by negligence of any of the Released Parties or other participants.

    Consent for Medical Treatment. If any of my children is injured or becomes ill while participating in a Swim Club Activity, an employee or volunteer of Valley Swim Club will use the contact information on this form to attempt to contact me. If such efforts to contact me are not successful, I hereby give consent to any medical treatment for my children which is deemed appropriate by an employee or volunteer of Valley Swim Club. This consent includes authorization of disclosure of protected health information concerning my children under the Health Insurance Portability and Accountability Act (45 C.F.R Part 164). I release the Released Parties from responsibility for any medical care arranged for or deemed necessary for my children, including releasing the Released Parties from responsibility for failure to provide necessary medical care. I will be responsible for all medical costs incurred for medical care provided to each of My Family members, including medical care provided pursuant to this paragraph, including costs of hospitalization, surgery, transportation, and emergency room or urgent care facility care.

    Rules and Expected Conduct. I understand that each of My Family members will be expected to obey all rules of Valley Swim Club and to follow instructions of Valley Swim Club employees and volunteer leaders. If any of My Family members does not follow all rules associated with Swim Club Activities, I will arrange for My Family to be transported home at my expense.

    Use of Identifying Information. I consent to Valley Swim Club using pictures of my children and the name, likeness, and voice of my children for any purpose whatsoever, without compensation.

    Confirmation of Information and Consent. I hereby represent that:
    a.) I am a custodial parent or guardian of all minor children named above, with authority to make the representations and releases from liability set forth herein,
    b.) I consent to each of My Family members participating in Swim Club Activities, and
    c.) all statements made in this form are true and correct.