|
Jazzie Pools, Spas, & Fitness L.L.C. |
429 S. Maple Avenue
Falls Church, Virginia 22046
Phone: 703-532-0242 Fax: 703-532-1381
www.JazziePools.com or Schedule@JazziePools.com
Registration
and Emergency Care Form
Please print: Child’s Name: ___________________________________________________________
Address: _______________________________________________________________
County, State, Zip code: ___________________________________________________
Date of Birth ______________________ Home phone number ___________________
Swim level you are registering for: __________________________________________
Time of class you desire and session (1 or 2): __________________________________
List allergies, unusual health issues and current medications child is using:
_______________________________________________________________________
Parent’s information:
Father’s Name _______________________
Work Phone # _______________________ Home phone # _______________________
Mothers Name _______________________
Work Phone # _______________________ Home phone # ________________________
Emergency Contact or doctor ___________________________________________
Phone Number: ______________________________________________________
Address: ____________________________________________________________
Release: We (I) hold harmless Life Foundation or Jazzie Pools for any injury that my child sustains while in the process of learning how to swim. I do expect preventive precautions to be used by the instructors & floatation devices, kick boards, etc. to be used when appropriate.
I/we (parent/guardian) authorize the pool management company, on behalf of Life Foundations, to obtain medical care if an emergency occurs when I/we cannot be located immediately. I will make every effort to have a person over 18 accompany my child to the lessons.
Parents Signatures _______________________________________ Date ____________
_______________________________________ Date ____________
|
|
|