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Aquatic Private Swim Lesson Form
Contact First Name: * Contact Last Name: * Participant 1 - First Name * Participant 1 - Last Name * Participant 1 - Date of Birth * Participant 2 - First Name Participant 2 - Last Name Participant 2 - Date of Birth Address: * City: * State: * Zip: * Daytime Phone Number: * Evening Phone Number: * Cell Number * Email Address: * Please select a package (all lessons are 30 minutes long with a maximum of two participants): * How many lessons per week are you requesting? * Please choose your available times: * Student Information - please check one: * Skills already mastered - please check the skills your swimmer has completed: * Please list any goals, special needs or comments: *
By initialing, I acknowledge that I have read and understand the Private Swim Lesson Policies listed on our website. Private lesson packages expire 1 year from date of purchase. I also agree to the City of Des Peres waiver of release and liability below. If accommodations due to a disability are needed to participate please call Terri Johnson, Inclusion Coordinator, at 314-835-6157. In case of inclement weather, please call 314-835-6102 (press 4, then 1) for program cancellation information. WAIVER OF RELEASE AND LIABILITY The Des Peres Parks and Recreation Department is not responsible for any injury or loss of property suffered while participating in Des Peres Parks and Recreation activities, using equipment, or on any Des Peres Parks and Recreation premises, for any reason whatsoever, including ordinary negligence on the part of Des Peres Parks and Recreation, its employees, instructors, or agents, from any and all present and future claims resulting from participation in activities both present and future, that may be made by the registrant, the registrant's family, estate, heirs, or assigns. By participating, you agree to having your picture or likeness represented and published in any City of Des Peres publication or media. By participating, you represent that you are in good health. You are aware that health, fitness and recreation activities may range from vigorous cardiovascular activity to the exertion of strength training; and that these, and other activities provided by Des Peres Parks and Recreation involve certain risks, including but not limited to death, disability, serious neck and spinal injuries resulting in complete paralysis, heart attack, and injury to bones, joints or muscles. By participating, you and your family are agreeing to voluntarily participate in activities with full knowledge of the inherent risks of property damage, personal injury, or death. You understand that Des Peres Parks and Recreation encourages you to consult a physician before beginning any exercise or recreation program. You understand and agree to this waiver to be as broad and inclusive as the laws of the State of Missouri will permit and affirm that you freely agree to the rules and regulations of the Des Peres Parks and Recreation Department. *
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