R/G R

MONTGOMERY

STROKE & TURN CLINIC

SUNDAY EVENING SWIM CLINICS

If you have any questions please email us at info@mstcswim.com

The participant assumes all risks associated with participation in the program; the City assumes no liability for injury or damages arising from participation in the program. Due to the strenuous nature of some activities, the City encourages each participant to consult his or her physician concerning fitness to participate in the program. The participant consents to emergency treatment. The participant also consents to the City’s use of any photographs taken or video tapes made of the program. If the participant is a minor, the parent or guardian approves his or her participation in the program. I, by confirming agreement, do hereby indemnify and hold harmless Montgomery Stroke and Turn Clinic Inc. (MSTC), Gaithersburg Aquatic Center, Rockville Swim and Fitness Center, or any servants, agents, proprietors or employees of the above from any and all liability, damage, expense, cause of action, suits, claims or judgments arising from injury to person or personal property or otherwise which arise out of the act or failure to act or negligence of the participants in connection with or arising out of the use of the facilities for this program. COVID-19 CONSENT FORM Assumption of Risk and Waiver, Relating to COVID-19 The coronavirus, COVID-19, is an extremely contagious virus which easily spreads from person to person. Federal, state, and local governments and health agencies may reinstate restrictions recommending or requiring social distancing and in some cases, limiting the total number of people that can be present within certain areas. There are currently no restictions in place but it should be noted; however, that participation in swimming practices and activities could increase the risk of exposure to and contracting COVID-19. Prior to participation in swimming practice and activities you will be requested to complete a self-symptom and temperature check. I acknowledge that by participating in MSTC practices and activities I, or my children, may be exposed to or infected by COVID-19 through no fault of MSTC, and such exposure could result in illness, disability, or even death. I understand the risk imposed by the disease and potential infection and voluntarily agree to assume all risks, to waive any claims against MSTC, and to assume personal responsibility for any illness, injury, disability of death to myself, or my children, and release and hold harmless MSTC, its owners, managers, officers, employees, agents, and representatives, excepting any acts of gross negligence. *

I Agree

Emergency Contact Number: *

Select Clinic: *

ROC 4:00-4:50

ROC 4:50-5:40

ROC 5:40-6:30

GAC 6:05-6:55

Parents Name: *

Additonal Information You would like to share about your swimmer:

Swimmer One's Name and Date of Birth : *

PLEASE READ AND FILL OUT ALL REQUIRED FIELDS OF THE REGISTRATION FORM AND CLICK THE "I AGREE" BUTTON TO REGISTER ONLINE. THEN CLICK THE "SUBMIT" BUTTON TO BE DIRECTED TO THE PAYMENT PAGE. REGISTRATION IS COMPLETE WITH RECEIPT OF PAYMENT.

Emergency Contact Name: *

Parents Email: *

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ROCKVILLE (ROC) AND GAITHERSBURG (GAC) ONLINE REGISTRATION FORM

Parents Contact Number: *

Parents Address *

Swimmer Three's Name and Date of Birth :

Swimmer Two's Name and Date of Birth :

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mONTGOMERY STROKE & TURN INC.