TOWN OF CONWAY PARKS AND RECREATION DEPARTMENT
2015 SWIM PROGRAM REGISTRATION
Name_______________________________
Age_____
Phone_________________
Address________________________________________________________________
NOTE: A parent or guardian must sign the waiver of liability on the back of this form.
CHECK CLASS ENTERING:
( ) Preschool (3 &4 yr. olds who are swimming for first time, accompanied by adult)
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Level I (doesn’t get face wet comfortably)
Level II (comfortable underwater)
Level III (can swim 5 yards on front and back)
Level IV (can swim front & back crawl, elem back)
Level V (knows breaststroke and sidestroke kicks)
Level VI (knows dolphin kick for butterfly stroke)
Jr. Life Saving (Beginner course on jr. lifesaving/lifeguarding) (Only a two week Session)
(30) minute lessons Mon-Thurs. afternoons for six weeks
Program will begin on June 29 and conclude on August 6th.
DEADLINE: June 22nd
The fee for this program is $60.00 per child for residents of Conway, Albany & Fryeburg, Maine.
Jr. Life Saving/Lifeguard training is $25.00 resident $50.00 non-resident
If you live outside of these areas, the non-resident fee is $80.00 per child.
Instructors reserve the right to change your child’s level according to ability. Applications
Will not be accepted after the deadline. Instructors cannot and will not accept applications or
payment for a class. All payments must be mailed or dropped off to the Conway Parks & Recreation
Director’s office. If a level doesn’t have at least (4) participants enrolled in it, the class will be
cancelled and money will be refunded.
Please make all checks payable to: The Town of Conway NO CASH PLEASE
Mail to: Conway Recreation Department, Attn: John Eastman
1634 East Main St.
Center Conway, NH 03813
A tentative class schedule will be posted at the Conway Recreation Department and Fryeburg
Recreation Department office on June 23rd. You can also access the schedule at our website:
www.conwayrec.com or www.fryeburgrec.com
John Eastman, Parks & Recreation Director 447-5680
Email: [email protected]
Conway Recreation Department
Release and Waiver of Liability and Indemnity Agreement
In consideration of the permission granted to my child,
______________________________________
(Print Name of Child)
Participant, to participate in the Conway Recreation Program, I/we do release, waive, discharge and
covenant not to sue the Town of Conway and its Conway Recreation Dept. including its paid and/or
volunteer agents and/or from all liability for any and all loss or damage, and any claim or demands
therefore on account of injury to the person or property or resulting in the death of our child, and/or
employees while I participate in the Conway Recreation Dept. Programs.
I/We further agree to indemnify the Town of Conway and the Conway Recreation Dept. , their paid
and/or volunteer agents and/or employees from any and all liability, loss or damage including but not
limited to bodily injury, illness, death or property damage which the Town of Conway and Conway
Recreation Dept. , their paid and/or volunteer agents and/or employees become legally obligated to pay
including reasonable attorney’s fees and costs, as result of claims, demands, costs or judgments against
the Town of Conway and/or Conway Recreation Dept. their paid and/or volunteer agents and/or
employees on account of injury to the person or property or resulting in the death of our child, whether or
not caused by the negligence of the Town of Conway, The Conway Recreation Dept., its paid and/or
volunteer agents and/or employees, and whether or not such liability is sole, joint or several.
I/We are aware that participation in this program may present strain on my child’s body , or parts and
therefore I represent to the Town of Conway and The Conway Recreation Dept. that to the best of my
knowledge, my child is in proper physical condition to allow him/her to participate in that I/We assume
the risk participating.
I/We understand that in case of injury or illness, I/we will be notified. If its is impossible to contact either
of us and it is an emergency, I/We give permission to the attending physician to treat, hospitalize,
administer anesthesia, or to other injections or surgery for the safety of my/our child.
I/We, the parent/legal guardian of my/our child who is participating in these programs, have read the
release and understand all its terms. I/We execute this agreement voluntarily and with full knowledge of
its significance. I/We have executed this release on the date below indicated.
I herby authorize the Conway Recreation Dept. to use photographs and video of my child to promote
these programs.
_______________________________
Signature of Legal Guardian
_______________________________
Today’s Date
_______________________________
Print Parents Name Clearly
_______________________________
Home Phone
_______________________________
Work or Cell Phone
______________________________________________________________________________
Additional Emergency Contact/Relationship/Phone Number
Please list any health concerns of your child of which staff should be informed: