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Printable Version
I, the parent or Guardian of _________________________, hereby acknowledge and agree to the following:
Waiver of Liability: Participation in swim practice and competition carries with it potential hazard and risk of bodily and other injuries. I, therefore, release the Ridgefield Aquatic Club, the town of Ridgefield, the Ridgefield Parks & Recreation Department, and any other potential practice or competition facilities, coaches, officials and any agents, employees, directors or others involved in any swim activities for which my child or ward (identified above) is registered from any claim for any injury or harm incurred as a result of such activity.
Medical Release & Treatment Authorization: I give my permission to the Ridgefield Aquatic Club personnel to authorize any and all medical attention required by my child or ward (identified above) in the event of an accident, sickness, illness or injury of whatever nature while engage in or associated with competitive swimming or other Club activities until I can be contacted. I also hereby assume the responsibility for payment for any such treatment given pursuant to this authorization. In addition, there are no medical conditions that I am aware of that would preclude my child from engaging in competitive swimming and related activities:
Insurance Company: _______________________________
Insurance Group #: __________________________
Other Insurance ID#: _______________________________
Physician: _________________________________
Physician Phone #: _________________________________
Allergies/Medication/Medical Conditions: ___________________________________
Emergency Contact Name: __________________________________________
Relationship: _____________________________
Phone #: __________________________________________
_______________________________________________________________________
Parent/Guardian Signature Date
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