2015 Randolph Swim Lessons and Jr. Lifeguard

Personal Information:

Youths Name______________________________________________________________________________________________________________________ D.O.B. __________________________ Grade Completed: ______________________ Gender: ________________ Skill level: ___________________________ Address: ________________________________________________________________________________Home phone: ______________________________ City__________________________________________________________State_______________________________Zip______________________________

Parent/ Guardian Information:*Note email will be the main contact for all communication Parent/Guardian 1: ____________________________________________________________________ Relation to Child: _______________________________ Day Phone: ________________________________________ Cell: _________________________*Email: ____________________________________________ Parent/Guardian 1: ____________________________________________________________________ Relation to Child: _______________________________ Day Phone: ________________________________________ Cell: _________________________*Email: ____________________________________________ Emergency Contacts (Other than Guardians) 1:____________________________________________________________________________________Phone:______________________________________ 2:____________________________________________________________________________________Phone:______________________________________ Medical Information:

Allergies / Medical Concerns / Medications: ______________________________________________________________________________________________ _________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Physician name: ____________________________________________________________________Phone: _________________________________________ Dentist name: ______________________________________________________________________Phone:__________________________________________

Please review the following and sign and date below to indicate your permission:

Release of Liability: I authorize the staff and volunteers of the Randolph Recreation Department to provide basic first aid or to call additional medical care on my childs behalf in the event of an emergency, if I cannot be reached or when delay would be dangerous to my childs health. I understand the inherent risk in participating in this program and hereby give my consent for the named applicant to participate in programs offered by the Town of Randolph Recreation

Department. I further agree to release the Town of Randolph and their staff and volunteers from any liability connected with my childs participation in the 2015 summer programs.

Consent: I hereby consent to and authorize the Town of Randolph Recreation Department the rights to publish, reproduce and use for advertising or any other purpose any photograph, video image, audio recording and other likeness of my child.

Parent/Guardian Signature: _____________________________________________________ Date: ___________________ Randolph Recreation Department, 7 Summer Street, PO Drawer B, Randolph, VT 05060

Phone (802) 728-5433 x 18 Fax (802) 728-5818 Email: rec@randolphvt.org

Sessions Dates Swim Lessons

Non-Camper: $40 Private Lessons (Randolph/Non Randolph) Session Lesson Time based on ability

(see below)

10 am 11am 12 pm 5 pm

1 lesson $25/$30

2 lessons $40/ $50

3 lessons $55/ $70

4 lessons $70/ $90

Swim Levels: 10am: Levels I,II,III 11am: Levels IV, V, VI 12pm: Pre-School 5pm: Levels I, II

5 lessons $75/ $100 (max)

Junior Lifeguarding: Rate: $50.00 Dates: TBD Ages: 11-15 Swim Club: Rate: $50,00 Dates: July MWF 11am Swim Team: Rate: $50.00 Dates:6/22-8/14 MWF 5pm

Payment Options

Families can pay with cash, check or money order made out to Town of Randolph. All payments are due prior to the start of each session.

Cancellation and Refunds:

o Participant cancellation: $25 registration fee is non-refundable o There will be no charge to move registration to a different program.

o No refunds after the program begins. In the case of medical or family emergencies, credits will be given for future programs.

o We reserve the right to cancel or combine programs with fewer than 8 students. Full refunds will be given if we cancel a program.

o Swim lessons will be held rain or shine. In the event of forecasted severe weather such as lightening, lessons may be canceled. No refunds will be offered until the last week of program you may reschedule to another week.

I understand that I am committing to the marked programs for my child and that once signed, I am responsible for paying the full fee to the Town of Randolph. I further understand that in order for my application to be complete, I must include a nonrefundable deposit of $25 a week per child per session with this form. I understand that if I wish to withdraw my child from any of these programs prior to the start date that refunds of program fees will be handled on a case by case basis.

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Date Recd _______ Amt Paid $________ circle: cash / check # _________ Staff Initials _________

Please return to: Randolph Recreation Department, PO Drawer B, 7 Summer Street, Randolph, VT 05060

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