1. sports
2. swimming

JOE FLAHERTY’S DOLPHINS 2015-2016
LESSON FORM
Swimmer’s Last Name
First
Middle
Age
Street Address
City
Birth Date
M/F
Home Phone Number
State
Mother’s Name
Zip
Cell Phone Number
Work Phone
Father’s Name
Work Phone
E-mail Address (for JFD billing & announcements only)
List your preferred coach or comments
Name of person who referred you (so they can receive the family referral credit)
Summer Swim Team
FEES – PAYMENT PLANS
PRACTICES PER WEEK (Please Circle One)
1
2
3
$706
$1,216
$1,556
Program Fee:
Discount Full Season Lessons
$
Ten Week Session 1&2
Session 1 ___ 9/21-11/22
$238
$426
Session 2___11/23-1/31
Twelve Week Session 3
___ 2/1-5/1
$286
$602
$511
$
$722
$
You will receive 10% off of each additional sibling’s program fee
$
$
Annual Registration Fee: Non-Refundable, $50.00
swimmer
Total
Number of Practices per week: _____
Days (circle)
Start Date: ___________
M
Tu
W
Th
F
Sa
50.00 per
$
Su
Time: |_____| |_____| |_____| |_____| |_____| |_____| |_____|
Circle Location: Quince Orchard
We are providing suits for our swimmers who register for a full season. A coupon will be sent to you through the mail
Option A: Please make checks payable and send to:
Joe Flaherty’s Dolphins, LLC.
16512 Roundabout Dr.
Gaithersburg, MD 20878
Or Fax to 301 916-2952
Or call 301-916-1852 with any questions! Email [email protected]
Payment Options: (Circle One)
Option A – Check (Please write your child's name on the check)
Option B – Credit Card additional 4% service charge
Please Charge My Credit Card: __ Visa __ MasterCard __Am. Express __ Discover
Account Number: __________________________________________ Exp. Date: _____________ Code ________
Signature: ________________________________________________________ Date: _____________
Skill Level
by Swimmer
Name of Swimmer
Child #1
Child #2
Child #3
Age as of 6/15/14
Goes under water
Yes
No
Yes
No
Yes
No
Can float & kick
Yes
No
Yes
No
Yes
No
Stroke Experience
None
Learning
Legal
None
Side Breathing
Backstroke
Breaststroke
Butterfly
C:\Users\Tim\Desktop\2015-2016 LESSON REGISTRATION FORM.doc 4/24/2015
Learning
Legal
None
Learning
Legal
Child’s Last__________________ Child’s First___________________ Circle: Team Clinic Lesson
EMERGENCY MEDICAL INFORMATION, LIABILITY RELEASE AND INDEMNIFICATION
I, the undersigned participant and parent, request voluntary participation for minor to participate in all events,
which are hereinafter referred to as the “activities.”
This agreement is valid while the participant is a member of Joe Flaherty’s Dolphins, LLC.
I consent to my/minor’s participation in the activities and acknowledge that the minor and I fully understand
that my/minor’s participation may involve risk of serious injury or death, including losses which may result not
only from my/minor’s own actions, inactions or negligence, but also from the actions, inactions, or negligence
of others, the condition of the facilities, equipment, or areas where the event or activity is being conducted,
and/or the rules of play of this type of event or activity. I understand that if I have any concerns about the risk, I
should discuss them with the activity coordinators and event staff, before I sign this document and before the
activity begins.
Release – Minor’s Rights:
In consideration of allowing Minor Participant to participate in the activities, I hereby release and hold harmless
Joe Flaherty’s Dolphins, LLC, employees, volunteers, other participants, and agents (collectively, the “Released
Parties”), of and from, and do discharge and waive, any and all claims, demands, losses, damages, and liabilities
that Minor Participant may have or sustain with respect to any and all damage and/or injury, of any type, arising
out of his or her participating in the activities. I also agree that if any portion of this agreement is held to be
invalid the balance, notwithstanding, shall continue in full force and effect.
(Print name of minor)
(Signature of minor)
(Date)
_______________________________
____________________________
_______________
Release – Parents’/Guardians’ Rights:
In consideration of allowing Minor Participant to participate in Joe Flaherty’s Dolphins, LLC Swimming
events, I hereby release and hold harmless the Released Parties, of and from, and do discharge and waive, any
and all claims, demands, losses, damages, and liabilities that I may have or sustain with respect to any and all
damage and/or injury, of any type, arising from Minor Participant’s participation in the activities. I also agree
that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full
force and effect.
I certify that my/minor is in good health and have no physical condition that would prevent participation in this
activity. I consent to emergency medical treatment in the event such care is required.
(Print name of Parent/Guardian)
(Signature of parent)
(Date)
_______________________________
____________________________
_______________
Indemnification by Parent/Guardian:
The undersigned parent/guardian further agrees to indemnify, save and hold harmless the Released Parties from
any and all claims, demands, losses, damages and liabilities for indemnities, contribution or otherwise with
respect to any damage and/or injury, of any type, arising from Minor Participant’s participation in the activities.
(Print name of Parent/Guardian)
(Signature of parent)
(Date)
_______________________________
____________________________
_______________
In the event of illness, accident or injury, permission is granted to have _________________________
treated by a physician.
Please note that our child is allergic to the following medications: ___________________________________
Please note that our child has the following health conditions: ________________________________________
Emergency contact if parents cannot be reached (Names, Relationship, and Phone Numbers)
Name________________________ Relationship_________________________ Phone _______________
Medical Insurance Carrier
__________________________________ Policy #: _____________________ Group # _____________(if applicable)
I give my permission for JFD to be photographed with the potential for use on JFD website and promotional material
Signature of Parent or Legal Guardian:
_________________________________________________
Phone _______________________
C:\Users\Tim\Desktop\2015-2016 LESSON REGISTRATION FORM.doc 4/24/2015
(date)
_______________