PRIVATE LESSON REGISTRATION Please enable JavaScript in your browser to complete this form.CONTACT INFORMATION:Name *Location *Select OneOcean City, MD.West Ocean City, MD.Fenwick, DE.Millville, DE.Oceanview, DE.Rehoboth, DE.Bishop's Landing ResidentKCCC MembersGlen Riddle ResidentCape Coral, FLFt. Myers, FL.Cell Phone *Email *Name and Address of Home, Community, Condo, or Vacation Pool *Address Line 1CityChoose StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact *Cell Phone *PRIVATE SWIMMER REGISTRATION:Name *D.O.B *Age *Gender *ChooseMaleFemalePREFERRED TIME SLOT:START DATE: *PREFERRED DAY *Choose DayMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYPREFERRED DAYChoose DayMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY (2nd choice - optional)PREFERRED TIME *Choose TimeBetween 8am - 2pmBetween 2pm - 6pmMONTHS AVAILABLE? Check all that apply *JuneJulyAugustSeptemberParticipation in Ocean City Aquatics is intended to promote healthy and safe swimming opportunities for myself, child and or children. Like many physical activities, swimming and associated activities pose certain inherent health risks that can result in serious injury (physical and/or emotional) or even death. I acknowledge and assume the risk inherent with myself, child/children active participation in Ocean City Aquatics. Failure to follow safety instruction may lead to my child/children suspension or cancellation of swim instruction. Discretion is left entirely to the Ocean City Aquatics staff to determine whether and when removal is appropriate. I give consent and permission for the taking of photography and/or video and/or audio of participants to be utilized for instruction and/or advertisement. Release and wavier: By signing this form, I acknowledge that I have been informed about certain risk and responsibilities in this program. I am acknowledging that I am knowingly and voluntarily assuming the risk. Further, by signing this form, I also agree, for myself, my heirs and assigns to release and hold harmless Ocean City Aquatics its employees and agents, from any legal claim or liability for any bodily injury and personal property damage that is caused to me by the negligent act or omission of persons not a party to this agreement. I further understand that my child/children cannot be left unattended during swim instruction. This waiver applies to all current and future swim classes and/or lessons taught by Ocean City Aquatics.PAYMENTPrivate lessons are $50.00 per swimmer / lesson.Payment Method *Choose your payment methodCharge to MembershipCheckCashPayment Method *Choose your payment methodCheckCashEnter Member Number *Please mail check payable to Ocean City Aquatics:603 Penguin Drive, Ocean City, MD. 21842Please bring your cash payment to your first practice. Parent or Guardian Signature (use mouse or finger to sign | x in upper right corner will clear the box) *Clear SignatureVerification * I have read and agree to the Participation, Release and Wavier.Security Verification * Type the word SWIM in the box below (this helps us cut down on spam)EmailSubmit
