Registration Form - Ginger Blackman

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You are registering for Swim Safe Now Lessons with Master Instructor, Ginger Blackman at 1695 Angel Ave, Merritt Island, FL, 32952. A tentative start date and lesson time should have already been confirmed with your Instructor. Start dates are subject to delays due to weather, illnesses and other factors.

*If this is not the correct Instructor or availability has not been confirmed, please do not continue as the Registration Fee is Non-Refundable.

Lesson Fees are paid directly to your Instructor and are not included in the Registration Fee.

Swim Safe Now Lessons are held 4 days per week, typically Monday - Thursday, for approximately 15 minutes per lesson.

Checkboxes *

I acknowledge that the Registration Fee is Non-Refundable and is valid for the current calendar year.

Parent/Guardian Information

Parent Name *

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Last

Relationship to Student *

Email *

Phone *

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Address *

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Contact

Name *

First

Last

Relationship to Student *

Phone *

Did someone refer you? Please list their name below so we can thank them and send a referral reward if applicable. We can only reward one person per new referral, so please list one name only.

I was referred by:

Student Information

STUDENT TYPE *

STUDENT NAME *

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Last

STUDENT GENDER *

STUDENT'S DATE OF BIRTH *

STUDENT ADDRESS *

Address Line 1

Address Line 2

City

State

Zip Code

Date / Time

Date

Time

Is this child currently being monitored or treated by a medical specialist other than his/her Primary Care Physician?

Does your child have any history of seizures (including febrile)?

MEDICAL HISTORY *

MEDICATIONS *

PHYSICAL FITNESS ACKNOWLEDGEMENT *

By checking this box, I confirm that to the best of my knowledge, this student has no medical, physical, or emotional health conditions which would hinder or prevent participation in Swim Safe Now Lessons. This student has been examined by a certified physician within the last year and is physically fit to participate in survival swim lessons.

PHOTO RELEASE *

I hereby grant permission to Swim Safe Now to use any photographs, videotape and/or digital images taken during lessons, for educational and/or marketing purposes. I authorize the use of these images indefinitely without compensation to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of Swim Safe Now. I will advise my instructor if I do not wish to have my child’s picture/video taken on picture days.

Click here to open/review/download/print a copy of the Pool Rules & Lessons Guidelines in a new tab then return to this tab to complete the form.

I AGREE TO THE POOL RULES & LESSON GUIDLINES OUTLINED ABOVE *

I have reviewed and agree to the Pool Rules & Lesson Guidelines. I understand that my child may be able to continue to participate in lessons if these rules are not followed in order to ensure the safety and success of my child in lessons.

WAIVER OF LIABILITY AND ASSUMPTION OF RISKS

In consideration of being allowed to voluntarily participate in any activities and/or programs taking place on the premises of Ginger Blackman’s home, or otherwise associated with Swim Safe Now LLC, Merritt Island Swim School, its owners and operators, the undersigned Parent or Guardian (hereinafter “Undersigned” and “I” interchangeably), on behalf of the minor participant(s) (herinafter “child(ren)” and “particant(s)” interchangeably) named below, hereby acknowledges, appreciates and agrees to the following: I represent that I am the parent or legal guardian of the minor participant named below and on this registration. As the legal parent or guardian, I for myself, the minor participant(s), any heirs, estate, successors and assigns release Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now, Merritt Island Swim School, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, slip, fall and/or negligent instruction or supervision, including death, that may be sustained by the participant and/or the Undersigned, while in or upon the premises or any premises under the control and supervision of Ginger Blackman, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators or in route to or from any said premises. I, for myself, the minor participant(s) named below, any heirs, estate, successors and assigns, hereby acknowledge, accept and assume all the risks and hazards arising out of or related to the participation of any activities taking place on Ginger Blackman’s premises or otherwise associated with Ginger Blackman, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators, resulting from the negligence of Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators.

This Waiver includes, but is not limited to, any claims against Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators for negligence or gross negligence of any kind or nature related to the design, layout, configuration, construction, maintenance, operation, supervision, instruction or advice, allowing another Instructor or Student Instructor to participate in a classes, subcontractor hiring and retention and any other aspect of interaction or facility use by or between Undersigned and Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators.

Undersigned acknowledges that Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators shall not be liable to Undersigned for any claims, demands, injuries, damages or actions or causes of action whatsoever arising due to injury to Undersigned, Undersigned’s child(ren), Undersigned’s guests or property arising out of or in connection with the use by Undersigned and/or Undersigned’s child(ren) and/or Undersigned’s guests, of the services or facility of Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators or the premises where same is located and Undersigned hereby releases and holds Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators harmless from all claims which may be brought against them by Undersigned or on Undersigned’s behalf for any such injuries or claims aforesaid and completely and irrevocably releases and waives his/her rights to any claims as otherwise outlined within this paragraph.

PARENTAL/ADULT SUPERVISION REQUIRED AND ACKNOWLEDGED

I acknowledge that Ginger Blackman’s home contains items such as toys and animals in the assigned swimming/waiting area I hereby acknowledge the child(ren) must use the toys, observe the animals and use the items and any areas at his/her/their own risk; I agree to monitor and protect the child(ren) at all times and I, the minor participant(s) any heirs, estate, successors and assigns, further hereby indemnify and hold harmless Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, brought as a result of any alleged injury sustained by the named child(ren).

ASSUMPTION OF RISK

I understand, agree, and acknowledge that there are risks inherent in swimming activities conducted by Swim Safe Now LLC and Certified Master Instructor, Ginger Blackman, and that the minor participants could suffer an injury. With the full understanding of the facts, I state that to the best of my knowledge, the minor participants listed has no medical, physical, or emotional health conditions, which would hinder or prevent his/her/their participation in Swim Safe Now LLC programs. My child(ren) has been examined by a certified physician within the last year and is physically fit to participate in survival swim lessons. He or she is free from any contagious disease. If any child listed below develops or has manifest a previously unknown medical/physical or emotional health conditions during his/her/their participation in Swim Safe Now LLC Lessons, I, for myself, the minor participant(s) any heirs, estate, successors and assigns continue to hold harmless and indemnify and hold harmless Ginger Blackman, her spouse, heirs and assigns, Swim Safe Now LLC, Merritt Island Swim School, its owners and operators from any and all claims, actions, suits, procedures, costs,expenses, damages and liabilities, including attorney’s fees, brought as a result of any alleged injury sustained by the named minor participants.

SEVERABILITY

I further agree and understand that this Waiver will extend to all claimed wrongful acts of the released parties to the greatest extent allowed under the laws of the State of Florida, including the negligence of any of the released parties. The Undersigned further expressly agrees that the foregoing Waiver is intended to be as broad and inclusive as is permitted by the laws of Florida and that if any portion thereof is held by a court of competent jurisdiction to be invalid, the Undersigned agrees that such provision will be deemed deleted from this Waiver without invalidating the remaining provisions of this Waiver or affecting the validity or enforceability of the remaining provisions.

I HAVE READ THESE RULES AND I ACCEPT AND AGREE TO FOLLOW THEM. I ALSO ACKNOWLEDGE THAT THIS IS MY BINDING CONTRACT THAT WILL BE VALID FOR THE ENTIRE DURATION OF LESSONS FOR AS MANY YEARS AS MY CHILD/CHILDREN IS/ARE IN LESSONS. IT IS UNDERSTOOD AND AGREED THAT THIS IS FULL AND FINAL RELEASE AND WAIVER OF ALL CLAIMS OF EVERY NATURE AND KIND WHATSOEVER IN CONSIDERATION OF BEING ALLOWED TO VOLUNTARILY PARTICIPATE IN ANY ACTIVITIES AND/OR PROGRAMS TAKING PLACE ON THE PREMISES OF GINGER BLACKMAN’S HOME, IN THE CASE OF A GUEST, IN EXCHANGE FOR ENTRY ONTO THE PREMISES AND/OR INTO THE PROGRAM.

I UNDERSTAND, AGREE, AND ACKNOWLEDGE THAT THERE ARE RISKS INHERENT IN SWIMMING ACTIVITIES CONDUCTED BY MERRITT ISLAND SWIM SCHOOL. WITH THE FULL UNDERSTANDING OF THE FACTS, I STATE THAT TO THE BEST OF MY KNOWLEDGE, MY CHILD LISTED HAS NO MEDICAL, PHYSICAL, OR EMOTIONAL HEALTH CONDITIONS, WHICH WOULD HINDER OR PREVENT HIS/HER PARTICIPATION IN MERRITT ISLAND SWIM SCHOOL PROGRAMS. MY CHILD HAS BEEN EXAMINED BY A CERTIFIED PHYSICIAN WITHIN THE LAST YEAR AND IS PHYSICALLY FIT TO PARTICIPATE IN SWIM LESSONS. HE OR SHE IS FREE FROM ANY CONTAGIOUS DISEASE.

PRINTED NAME OF CHILD/MINOR PARTICIPANT *

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Last

PRINTED NAME OF PARENT OR GUARDIAN/ADULT PARTICIPANT *

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Last

Signature

Message

Registration Form – Ginger Blackman

Parent/Guardian Information

Secondary Contact

Student Information

WAIVER OF LIABILITY AND ASSUMPTION OF RISKS

REGISTRATION PAYMENT