Swimmer Name (s) *

Email *

Date of Birth (s) MM/DD/YYYY *

Name of Parents / Legal Guardians

Address *

City/Town *

State/County *

Zip/Post Code *

Phone *

If you are not attending the Full Camp, please list sessions you wish to attend

What are your expectations from the camp? *

How many hours per week do you train? *

Are you training for a particular competition or purpose? *

What are your personal best times in your best events? *

Is there anything else we should know about you, excluding medical information? Do you have any special requests? *

I hereby agree and consent to your photographing, filming, taping and/or recording my likeness, voice, sound and quotes, knowing that you will incur substantial expense in reliance upon this Consent, Release, and Authorization (this “Consent”), and for other good and valuable consideration, the adequacy and receipt of which is hereby acknowledged, I hereby grant to you and your parent, related and affiliated companies, and their respective licensees and assigns, and the directors, officers, employees and agents of each, forever and throughout the world, the right to use and license and the right to reuse such photographs, films, tapes and/or recordings of my likeness, voice sound, quote and my name, in all media, whether now known or hereafter devised, throughout the universe in perpetuity (including, without limitation, in films, newspapers, magazines, on radio, television, commercials, merchandise, video cassette, video disk, exploitations, digitized images, whether for advertising, publicity, or promotional purposes and for any other purpose what so ever, without further compensation to me or any limitation whatsoever. In granting this license, I understand that The Race Club is not under any obligation to exercise any of its rights, licenses and privileges herein granted.I hereby release The Race Club from all claims, demands, liabilities, damages, costs and expenses (including, but not limited to, attorney’s fees and fees of other professionals) that I may now or hereafter have against The Race Club arising in connection with the use of my likeness, voice sound, and quote in such photographs, films, tapes and/or recordings and your exercise of the rights hereby granted.This consent shall be binding upon my heirs, personal representatives and me and assigns and shall be governed by and construed under the laws of the State of Florida. I certify that I am 18 years of age or older.

I hereby hold The Race Club and its staff free from all liability should any injury or illness befall me while I am in attendance at The Race Club Camp. I also authorize The Race Club Staff to secure medical treatment for me should I not be able to request such treatment for myself. I have no knowledge of any existing physical impairment that would affect my participation in this program. In addition, I authorize The Race Club to use any photographs of me taken during the program for use in publicizing and advertising future Race Club Swim Camps. In consideration of being allowed to participate in any way with (Name of Organization), its related events and activities, I, by agreeing to this online form, acknowledge, appreciate, and agree that: The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately; and, I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS (Name of Organization) their officers, officials, agents and/or employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. *

I certify that I have, or that my child has my, permission to participate at The Race Club Camp for the period mentioned below. I do hereby delegate to The Race Club, its employees, clinicians, trainers, nurses, agents, or representatives, the authority to seek, obtain, and approve any medical care and treatment including, but not limited to x-ray examination, anesthetic, medical, dental, or surgical diagnosis, or treatment and medical care which is deemed advisable by, and is to be rendered under the general supervision of any physician or surgeon, for me or my child or children which, in their judgment, is necessary for the health and well-being of myself or my child or children during his/her/their participation at The Race Club. I accept responsibility for medical charges, which may be incurred on my or my child’s or children’s behalf. It is understood that this authorization is given in advance of any specific diagnosis, or treatment, or medical care being required and is to serve as specific consent to any and all such diagnoses, treatment, or hospital care which may be deemed advisable. I understand that I am responsible for any cost incurred that is not covered by insurance and I agree to hold The Race Club, its employees, officers, representatives, and agents harmless for any liability arising out of any good faith effort taken in and obtaining medical treatment for me or my child or my children. I hereby give consent and permission to The Race Club to authorize medical treatment. I certify that I am 18 years of age or older. *

The Race Club reserves the right to cancel all, or any portion of, the camp/privates due to weather, acts of God, or any other reasons within or beyond it’s control. A $250 deposit fee is taken at the time of registration and is non-refundable unless The Race Club cancels a camp/privates due to unforeseen circumstances. Any cancellation made under 30 days but over 14 days prior to the start of the camp/privates will be charged 50% of the total cost of the camp/privates. Any cancellation made less than 14 days prior to the start of the camp/privates, the total cost of the camp will be charged. In order to protect their camp/privates investment against loss of camp/privates tuition due to injury, illness, or other covered circumstance, campers are encouraged to purchase travel insurance. The camp/privates does not provide coverage. Go to www.insuremytrip.com to create your own personal insurance policy and get insurance quotes from different insurers. *

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I consent to my submitted data being collected and stored as outlined by the site .