Waiver
of Claim Form
In consideration of the
acceptance of this entry and on behalf of
each of the listed competitors we ____________________________________ hereby waive and release any
and all claims against the United States
Government, NTTC Corry Station, NAS Pensacola, the Aquatic Development Group,
Inc., the Pensacola Navy Youth Swim Team, Washington High School, the
Bodenhamer Recreation Center and municipality of Gulf Shores, United States Swimming,
Inc. and Southeastern Swimming, Inc. and their officers, agents and
representatives for any and all injuries which may be sustained at this meet or
while in transit to and from this meet.
We _____________________ expressly
agree to waive claim as condition of being allowed to enter this meet. Further, we ____________________________________
affirm that all athletes entered in this meet and all coaches are current
members of United States Swimming and that all coaches are in compliance. I
hereby affirm that all of the swimmers we are entering in this meet are members
in good standing of United States Swimming.
I further affirm that all coaches for this team are listed on this
document and are Coach members of United States Swimming.
Signature
of coach or club official __________________________________________________________
CLUB_________________________________________________________________________________
Date:
_________________ Title:
___________________________________
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Team
Information
Team
Name: _____________________________________
Initials:
___________________
Email
Address : __________________________________________
LSC:
________________________ Coach:
_______________________________________
Address:_______________________________________________________________________________
Phone:
(W) __________________________ (H)
____________________________________
Person
to contact for questions on entry: _____________________________________________________
Phone:
(W) __________________________ (H)
_____________________________________
Certified
Officials who may wish to work:
1.
________________________________ 2.
______________________________________
3.
_________________________________ 4.
_____________________________________
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Total
Number of Swimmer Surcharges ______
x $3.00 = $__________
Total
Number of Individual Events Entered ______
x $3.00 = $__________
Total
Number of Relays Entered ______
x $8.00 = $__________
Total
Amount Enclosed
$__________