PRIDE Swim Team Swimmer Form

PGPR
PRIDE
SWIM TEAM
Prince George’s County
This form must be completed/verified for every
Swim Team Swimmer
Form
swimmer prior to
the start of each season.
1. SWIMMER INFORMATION
Name
Birthdate (M/D/Y)
Shirt Size (circle one)
Address
City, ST Zip Code
Mother/Guardian Name
Email address:
(H)
(W)
(Cell)
Father/Guardian Name
Email address:
(H)
(W)
(Cell)
Emergency Contact Name
(H)
(W)
(Cell)
AS AM AL
AXL A2X
County
(other than parent/guardian)
2. HEALTH/OTHER INFORMATION (MUST BE COMPLETED IN ITS ENTIRETY.)
Physician’s Name/Clinic Name
Phone #
(where medical records are kept)
a. Is the swimmer home-schooled or does the swimmer attend a DC or an out-of-state school?
 No. Name of MD school (public or private) attended this year __________________________ City, ST __________________
 Yes. Please complete Maryland Department of Health and Mental Hygiene Immunization Certificate or attach shot records.
b. Is the swimmer exempted from immunizations for religious or medical reasons?
 No. Date of last tetanus or DPT shot (REQUIRED BY MARYLAND STATE LAW FOR INDIVIDUALS UNDER 18) (MM/YY) ______
 Yes. Please complete Maryland Department of Health and Mental Hygiene Immunization Certificate.
c. Does the swimmer have any health issues/concerns (i.e., seizures, asthma, allergies)?
 No.
 Yes. Please explain: ________________________________________________________ Date of last seizure: ____________
d. Is the swimmer allergic to any food(s)?
 No.
 Yes. Please list food(s): ___________________________________________________________________________________
Reaction level:
____ Mild
____ Moderate
____Severe
Required treatment: ________________________________________________________________________________
e. Is the swimmer allergic to any medication(s)?
 No.
 Yes. Please list medication(s): ______________________________________________________________________________
Reaction level:
____ Mild
____ Moderate
____Severe
Required treatment: ________________________________________________________________________________
f. Does the participant have any environmental allergies, i.e., insect bites, pollen, poison ivy, etc.?
 No.
 Yes. Please list allergy(-ies): ________________________________________________________________________________
Reaction level:
____ Mild
____ Moderate
____Severe
Required treatment: ________________________________________________________________________________
g. Will any emergency medical device be provided, e.g., EpiPen®, inhaler, insulin pump, etc.?
 No.
 Yes. Please complete Medication Form and device must be kept with the participant at all times.
h. Is the swimmer currently taking any medication(s)?
 No.
 Yes. Please complete Medication Form.
i. Are there any physical, psychiatric, behavioral, emotional, or developmental concerns staff should be aware of?
 No.
 Yes. Please explain: ______________________________________________________________________________________
j. Will your child need assistance (Inclusion Services, such as, support staff, adapted equipment, etc.) to participate? (NOTE:
Accommodations must be requested two weeks in advance of program start date.)
 No.
 Yes. Please explain: ______________________________________________________________________________________
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3. SPECIALIZED ACTIVITY LIABILITY RELEASE/AGREEMENT/AUTHORIZATION/RELEASE
PARENT/GUARDIAN MUST INITIAL AFTER LISTED CHECKED SPECIALIZED ACTIVITY:
Specialized Activity: [] SWIMMING ________
(parent/guardian initials)
RELEASE OF LIABILITY & PARENT/GUARDIAN’S AGREEMENT/AUTHORIZATION/RELEASE: I understand that participation in the
specialized activity set forth above carries inherent risks including the risk of serious injury or death. I acknowledge that any activity
involving, but not limited to: water, height, motion, and rotation in a unique environment may be extremely hazardous. I
understand and acknowledge that participation in any of the listed activities is purely voluntary, and participants should not
participate in any activity beyond their physical or medical condition, which makes them uncomfortable, or which they consider
unsafe. By way of this form, I authorize the staff of the M-NCPPC to obtain medical/hospital treatment for the above participant in
the event of an emergency.
4. FIELD TRIP LIABILITY RELEASE/AUTHORIZATION/WAIVER OF LIABILITY
I hereby and represent that if the participant is a minor, I am his/her parent/guardian and authorized to provide the releases,
authorizations, and permissions stated herein and all the information provided is accurate and complete. I hereby give permission
for the participant named above to participate in the Maryland-National Capital Park and Planning Commission’s program, including
transportation in approved vehicles (M-NCPPC Vehicles, Board of Education School Buses, or Commercial Motor Coaches). I
acknowledge that the M-NCPPC Department of Parks and Recreation has a policy for conduct in recreation programs and facilities
and I hereby agree that the participant is subject to said policies, including the disciplinary provisions.
I, individually and on behalf of my child/ward, for any and all heirs and personal representatives, do hereby release and forever
discharge the Maryland-National Capital Park and Planning Commission (“Commission”), as well as individuals and entities related to
the Commission, including but not limited to the Commission’s commissioners, directors, officers, employees, agents, principals,
attorneys, and successors and all persons acting by, through, under or in concert with any of them from any and all claims,
obligations, debts, demands, actions, causes of action, suits, accounts, covenants, contracts, agreements, and damages whatsoever
of every name and nature, both in law and equity, which I now have or in the future may have relating to, occurring during, or
arising out of, any injured sustained by me or my child as a result of his/her participation in the programs stated above.
PLEASE READ CAREFULLY. THIS RELEASE OF LIABILITY CONTAINS A RELEASE OF KNOWN AND UNKNOWN CLAIMS BY YOU AND YOUR
CHILD. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THIS RELEASE OF LIABILITY, AND KNOWINGLY
AND VOLUNTARILY SIGN BELOW:
Print parent/guardian name
Date
Signature
5. COMPLETION OF FORMS
By signing below, I acknowledge that I have read, understood, and all information in the above sections are accurate and current.
(Forms must be reviewed annually. Please sign ONLY ONE line each time form is reviewed.)
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature
Print parent/guardian name
Date
Signature