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Youth Medical Release

Registration and Medical Release

Date of Birth
Month
Day
Year

Medical Information

Any pregnancy or delivery problems?
Yes
No

What the child delivered

Was oxygen required?
Yes
No
Pediatric ICU?
Yes
No

Developmental Milestones: (months)

Please check if the swimmer has any of the following:

Aquatic History

Has or vacations near

Aquatically skilled?
Yes
No
Has swimmer ever had an aquatic accident/incident?
Yes
No

Agreement and Authorization

I have discussed and understood the nature of this program. I give my consent to Terry Brown/Coastal Current Aquatics for my child to participate in this program as outlined. By signing this, I understand there are no refunds except for pool closure and no make up times are available.

I also agree that any pictures or videos taken of my child while in lessons may be used for future CCA promotions.
Yes
No
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Waiver of Release for Liability/Medical Treatment

The participant(s), family and guests of participants hold Terry Brown/Coastal Current Aquatics, any property owners/lessors, harmless of any and all liability. I fully understand and release the aforementioned entities of any liability. I hereby authorize any medical treatment,  which may be advised during lessons.

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Disclaimer

All personal and health-related information shared in this context is treated as confidential and will not be disclosed except as required by law.

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