PCA Winter II &nbs= p; Green & Red Groups

Feb. 4/5 – Mar. 26/27

(Please return one application plus the consent/release form for each swimmer)

Please fill out page 2= of the application listing your 1^st, 2^nd, 3^rd, etc. choices of classes.

Sign-up Date _______ &= nbsp; Current Swimmer _________ Former Swimmer < Fall Summer R= 17;07 >

Swimmer Name: _____________________________________________________________________<= /o:p>

&= nbsp; &nbs= p; Last<= span style=3D'mso-tab-count:4'> &= nbsp; &nbs= p; &= nbsp; &nbs= p; first &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; middle

Parent’s Names: ___ = _

Address: ______________________________________________________________________=

City: _____________________________________________________ = Zip:___________

Sex: M F Phone: Home: _____________________ Work: ____________________

Age: ______ Birthdate: ___________= ____ School: ______________________ Grade:_______

E-mail Address Mother _______________________________________

E-mail Address Father ________________________________________

E-mail Address Swimmer _____________________= ________________

Emergency Contact: _______________________________________ Phone: _______________

( ) PCCC Member Account Number _________________________________

Winter II Session Fees: &nb= sp;

First Child = ; <= /span>Green $60 &= nbsp; &nbs= p; &= nbsp; Red = $140

&nbs= p; &= nbsp; &nbs= p;

&= nbsp; Second Child &n= bsp; less $20.00 per session &= nbsp; Third Child &n= bsp; FREE

As parent/legal guardian of ______________________________________, I hereby g= ive my permission for a representative of the Peninsula Covenant Community Cent= er Staff to obtain medical attention for the above named participant in swim t= eam activities.

___________________________________________________ signature of parent/guardian<= /o:p>

Please complete = all four pages of the application, attach check and return to PCA

      Current sw= immer, forms are on file

PCA Dolphins   Winter II Session

       Feb. 4/5 – Mar. 26/27<= o:p>

Please mark class request, attach a check and retur= n to PCCC. Classes will be confirmed ASAP by e-mail.

Name ___________________________________    Birthdate______         = Age _______

Have you been evaluated by a PCA coach? Level ____    On what date?   ________

Parent’s e-mail address ____________________________________________________

Green Groups      Level 1

Please cir= cle your class request

Priorit= y        &= nbsp;        Group        &= nbsp;   Time        &= nbsp;           &nbs= p;   Days        &= nbsp;       _______

1^st 2^nd 3^rd 4^th        Green A         3:45-4:15 PM        &= nbsp; Wed    at PCCC        &= nbsp;

1^st 2^nd 3^rd 4^th        Green B         4:15-4:45 PM        &= nbsp; Wed    at PCCC        &= nbsp;

Red Groups            =             &nb= sp;       Level 2, 3 & 4 (all levels in each class)

Please cir= cle your class request

Priority=         &= nbsp;        Group        &= nbsp;   Time        &= nbsp;           &nbs= p;   Days        &= nbsp;               =                 Ages

1^st 2^nd 3^rd 4^th        Red A        &= nbsp; 4:45-5:25        &= nbsp;       Mon & Wed    at PCCC<= span style=3D'mso-tab-count:1'>        &= nbsp; 7-10

1^st 2^nd 3^rd 4^th        Red B&= nbsp;          5:25-6:0= 5        &= nbsp;       Mon & Wed    at PCCC<= span style=3D'mso-tab-count:1'>        &= nbsp; 10-13

1^st 2^nd 3^rd 4^thR= ed D&= nbsp;          4:45-5:2= 5        &= nbsp;       Tue & Thu     &nbs= p; at PCCC      &nb= sp;   7-10

1^st 2^nd 3^rd 4^th        Red E&= nbsp;          5:25-6:0= 5        &= nbsp;       Tue & Thu     &nbs= p; at PCCC      &nb= sp;   10-13

1^st 2^nd 3^rd 4^thR= ed F&= nbsp;           6:= 05-6:45        &= nbsp;       Tue & Thu     &nbs= p; at PCCC      &nb= sp;   All

Please indicate class priority, 1^st, 2^nd, 3^rd, wh= en completing application.

= ;

Please use separate Select Group Application Form for Bronze, Silver and Gold Grou= ps.
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY

Member and any Guest of Member hereby acknowledges and agrees that their use of facilities, services, equipment or premises and their participation in programs, outings and events whether o= n or off the premises of Peninsula Covenant Community Center (PCCC) may involve risk of injury to persons and property, includ= ing those described below, and Member and any Guest of Member assumes full responsibility for such risks. In consideration of being permitted to enter and/or participate in activities of Peninsula Covenant Community Center for any purpose including, but not limi= ted to, observation, use of facilities, services or equipment, or participation= in programs, events and outings in any way, whether on or off the premises of Peninsula Covenant Community Center, Member and any Guest of Member agrees to the following:

Member and any Guest of Member hereby releases and holds Peninsula Covenant Community Cen= ter (PCCC) and Peninsula Covenant Church (PCC) and their directors, officers, employees, affiliates and agents harmless from any and = all liability to Member and Member's personal representatives, guests, assigns, heirs, and next of kin for any loss or damage of whatsoever nature to Member or any guest of Member.

Member and any Guest of Member hereby expressly waives any claim of liability for personal/bodily injury or damag= es of whatsoever nature or kind which occurs to member or any guest of member and for any loss of or injury to person or property of whatsoever nature whether on or off the premises of PCCC. This waiver includes, = but is not limited to any loss, damage or destruction of the personal property = of the Member of any guest of any Member and is intended to be a complete release of any responsibility for any personal injuries and/or property loss/damage sustained by any Member or any guest of any Member whether= on or off the premises of PCCC.

Member and any Guest of Member = also hereby agrees to indemnify Peninsula Covenant Community Center (PCCC) and Peninsula Covenant Church (PCC) and their directors, officers, employees, affiliates from any loss, liability, damage = or cost incurred as a result of any claim of whatsoever nature made by Member, Member's agent or Member's guest.

Member represents (a) that Memb= er is in good physical condition and has no disability, illness, or other condition that could prevent Member from exercising without injury or impairment of health, and (b) that Member has consulted a physician concern= ing an exercise program that will not risk injury to Member or impairment of Member's health. Such risk of injury includes (but is not limited to): inju= ries arising from use by Member or others of exercise equipment and machines; injuries arising from participation by Member or others in supervised or unsupervised activities or programs at PCCC; injuries and medical disorders arising from exercising at PCCC such as heart attacks, strok= es, heat stress, sprains, broken bones, and torn muscles and ligaments,   among others; and accidental injuries occurring anywhere in PCCC dressing rooms, showers and other facilities and including injuries off premises relating to a PCCC activity. Member and Member's guest acknowledges that PCCC has not and will not render any medical services including medical diagnosis of Member = or Member's guest's physical condition.

Member further expressly agrees that the foregoi= ng release, waiver and agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion the= reof is held invalid, it is agreed that the balance shall, notwithstanding, cont= inue in full force and effect. Member has read this release and waiver of liabil= ity and indemnity clause, and agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.I hereby affirm that I have read and fully under= stand the above information.

Parent Name Printed _____________________________________________

Signature_______________________________________ Date __________

CONSENT/RELEASE FORM

In my absence and in the event of any emergency regarding my childr= en, I hereby authorize the mentio= ned emergency contact person(s) or an adult leader of this program, as agent for me, to consent to any x-ray examination; medical, dental or surgical diagno= sis; treatment; and hospital care advised and supervised by a physician, surgeon= or dentist (as appropriate) licensed to practice under the laws of the state w= here the services are rendered, either at a doctor’s office or in any hospital. I expect to be cont= acted as soon as possible.

Medical Information:

Child’s Name __________________________________ Age ____ Birthdate ________

Parent’s Name ___________________________________________________________

Address____________________________________________________________= _____

City_________________________________ Zip____________ Phone ______________

        &= nbsp;

Allergies (especially to medication) ________________________________________________= _

Current medications _____________________________________________________________

Physical limitations ______________________________________________________________<= o:p>

Medical Insurance Co. ___________________________________________________________

Doctor ________________________________________________________________________

Dentist ________________________________________________________________________

Emergency Contact __________________________________________ Phone No.___________

Emergency Contact __________________________________________ Phone No. __________

I hereby affirm that I have read and fully understand the above information.<= /span>Parent’s Signature ______________________________________ Date _________________        &= nbsp;           &nbs= p;            &= nbsp;

Revised

Swimmer Name: _____________________________________________________________________<= /o:p>

Parent’s Names: ___________________________ = _________________________

Have you been evaluated by a PCA coach? Level ____ On what date? ________

Green Groups Level 1

Red Groups = &nb= sp; Level 2, 3 & 4 (all levels in each class)

= ;

Please use separate Select Group Application Form for Bronze, Silver and Gold Grou= ps. RELEASE AND WAIVER OF LIABILITY AND INDEMNITY

CONSENT/RELEASE FORM

Parent’s Names: ___ = _

Have you been evaluated by a PCA coach? Level On what date? ____

Please use separate Select Group Application Form for Bronze, Silver and Gold Grou= ps.
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY