UNC Aquatics

PRIVATE SWIM LESSONS REGISTRATION FORM

UNC Aquatics offers quality aquatic instruction based on the American Red Cross Learn to Swim Program. Classes are
taught by Water Safety Instructors or instructors with similar qualifications. For additional information on these classes,
please click on www.aquatics.unc.edu or contact Marty Pomerantz at 962-2779.

Name of Participant: Age: Gender: PID Number:

Name of Parent/Guardian and PID Home Work
(if participant is < 18yrs): Phone: Phone:

Address:

Cell Phone: Email:

Emergency Contact (other than above) – Name: Phone:

HOW WOULD YOU CLASSIFY YOURSELF: WHAT ARE YOUR SWIMMING GOALS?
Beginner swimmer with no experience
Beginner swimmer with some experience
Intermediate swimmer
Advanced swimmer HOW MANY TIMES A WEEK DO YOU WISH TO MEET?

PLEASE CHECK THE PACKAGE SELECTED: (All sessions are 45 minutes)

One student (1:1 ratio): 1 session - $20.00 4 sessions - $75.00 8 sessions - $140.00
Two students (1:2 ratio)*: 1 session - $35.00 4 sessions - $120.00 8 sessions - $200.00
* 2 students must be of similar skill level

PLEASE CIRCLE ALL YOUR PREFERRED DAYS & TIMES THAT YOU ARE AVAILABLE:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

6:00 –8:00AM 6:00 –8:00AM 6:00 –8:00AM 6:00 –8:00AM 6:00 –8:00AM 1:30-2:30 PM
Lunch Swim Lunch Swim Lunch Swim Lunch Swim Lunch Swim Noon – 1:00 PM 2:30 – 3:30 PM
4:00 – 5:00PM 4:00 – 5:00PM 4:00 – 5:00PM 4:00 – 5:00PM 4:00 – 5:00PM 1:00 – 2:00 PM 3:30 – 4:30 PM
5:00 – 6:00PM 5:00 – 6:00PM 5:00 – 6:00PM 5:00 – 6:00PM 5:00 – 6:00PM 2:00 – 3:00 PM 4:30 – 5:30 PM
6:00 – 7:00PM 6:00 – 7:00PM 6:00 – 7:00PM 6:00 – 7:00PM 6:00 – 7:00PM 3:00 – 4:00 PM
7:00 - 8:00PM 7:00 - 8:00PM 7:00 - 8:00PM 7:00 - 8:00PM
8:00 - 9:00PM 8:00 - 9:00PM 8:00 - 9:00PM 8:00 - 9:00PM

Please return form and payment (cash or check

made payable to Dept. EXSS) to: Total Amount Paid:______________
UNC Aquatics Attn: Marty Pomerantz Office Use Only: Instructor:_____________
Campus Recreation, CB# 8610
University of North Carolina Schedule:
Chapel Hill, NC 27599-8605

You will be contacted within 3 business days to schedule the first session.
 RELEASE AND INDEMNITY AGREEMENT AND CONSENT FOR MEDICAL TREATMENT
As a part of the consideration for my participating in the University of North Carolina at Chapel Hill Aquatic School program, I
hereby release, hold harmless, and forever discharge The University of North Carolina at Chapel Hill, its employees and agents, from
any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, property damage,
or personal injury, including death, that may be sustained by me or to any property belonging to me while participating in such
activity. I acknowledge that said participation in this activity is elected by me and is not required. I understand that some of the
activities in this program pose a risk of injury, disability, and even death. I voluntarily assume full responsibility for any risk of loss,
damage, or personal injury, including death, and any property damage that may be sustained by me/my child as a result of such
activity.

I understand and acknowledge that it has been recommended that I have a physical examination and consult with a physician about
physical activity and exercise before participating in this program, especially if I have any physical conditions that may be harmfully
affected by the activities involved in the program, including, but not limited to, heart, circulatory, respiratory, or musculoskeletal
conditions. I acknowledge that I have either had a physical examination and been given the examining physician’s permission to
participate or that I have decided that I will participate in this activity without a physician’s approval.

By return of this form, I agree to inform the University of North Carolina at Chapel Hill Aquatic Program of any health or medical
condition or need that may affect my/my child’s participation in this program. I understand that I must make provision before my/my
child’s arrival in Chapel Hill for continuation of medical treatments such as prescriptions or special diets.

In the event of illness or injury, I hereby authorize the program director or instructors or other agents to obtain emergency or other
medical treatment for me as deemed necessary, including administration of an anesthetic or other medication and surgery, and I hereby
assume the cost of such treatment. I understand that this authorization is given in advance of any specific diagnosis, treatment, or
hospital care being required but is given to provide authority and power on the part of the University to give specific consent to the
diagnosis, treatment, or hospital care which in the best judgment of a licensed physician is deemed advisable.

I further agree to indemnify and hold harmless the University, its employees and agents, from any loss, liability, damage or cost,
including court costs and attorney’s fees that they may incur due to my participation in this activity, except that caused by the
negligence of the University, its employees or agents.

This release and indemnity agreement is binding on myself, my heirs, assigns, and personal representatives. If the participant is under
age 18, this form must also be signed by his or her parent or guardian, and all references to “me” or “my” in this document shall be
understood to include both the participant and his or her parent or guardian. By signing this document in the blank marked “Signature
of Parent or Guardian,” I also acknowledge that I am the parent or guardian of ________________________.
Name of participant

_______________________________________
Signature of Participant (if participant is over 18) Date

_________________________________
Signature of Parent of Guardian (if participant under 18) Date