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Swim With Gina Enrollment Form

Regarding COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Swim With Gina has put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending lessons could increase your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending swim lessons with Swim with Gina and team or being at the location of these lessons and that such exposure or infection may result in personal injury, illness, permanent disability, and death.

I understand that the risk of becoming exposed to or infected by COVID-19 at lessons or any of the facilities where lessons are taught may result from the actions, omissions, or negligence of myself and others, including, but not limited to Swim with Gina employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at swim lessons.

On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Swim With Gina, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.

I understand and agree that this release includes any claims based on the actions, omissions, or negligence of Swim With Gina, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during or after any participation in lessons with Swim with Gina or team.

Waiver and Release of Liability:

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of training and water activities. These risks include, but are not limited to injuries and/or death. I am willing to assume full responsibility for the risks that I am exposing myself or child to and accept full responsibility for the risks involved.

I acknowledge, I nor my child have any physical impairments, injuries, or illnesses that will endanger me or others while participating.

I Agree

Release:

In consideration of the above mentioned risks and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by James and Gina Hester. I the undersigned hereby release, forever discharge and agree to hold harmless James and Gina Hester, Swim With Gina, their employees, lifeguards, helpers or volunteers, as well as release ALL the facilities from which they teach, including but not limited to their home, Trinity Episcopal School, The Challenge at Oak Forrest Country Club, Pinecrest Country Club, and any private residence from which they teach, from any and all liability, claims, demands, actions or right of action which are related to, arise out of, or are in any way connected with my participation. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. I am including, but not limited to, instances of personal injury, sickness or death, as well as any property damage and expenses of any nature whatsoever as a result of participation in any class or activity offered by James and Gina Hester.

Authorization for Emergency Medical Attention:

If I am signing on behalf of a minor child, I also give full permission for any person connected to James and Gina Hester or Swim With Gina, to administer first aid/CPR deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.

I Agree

I have read and understood the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.

I Agree

May 18, 2021

First Participant Name

First Name*

Last Name*
First Participant Date of Birth*
First Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
First Participant Signature*
Second Participant Name

First Name*

Last Name*
Second Participant Date of Birth*
Second Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Third Participant Name

First Name*

Last Name*
Third Participant Date of Birth*
Third Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Fourth Participant Name

First Name*

Last Name*
Fourth Participant Date of Birth*
Fourth Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Fifth Participant Name

First Name*

Last Name*
Fifth Participant Date of Birth*
Fifth Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Sixth Participant Name

First Name*

Last Name*
Sixth Participant Date of Birth*
Sixth Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Seventh Participant Name

First Name*

Last Name*
Seventh Participant Date of Birth*
Seventh Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Eighth Participant Name

First Name*

Last Name*
Eighth Participant Date of Birth*
Eighth Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Ninth Participant Name

First Name*

Last Name*
Ninth Participant Date of Birth*
Ninth Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Tenth Participant Name

First Name*

Last Name*
Tenth Participant Date of Birth*
Tenth Participant Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Participant Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional Enrollment Information

To be filled out by parent.

Mother's Information (First/Last Name, Employed By)


Mother's Primary Phone: *

Father's Information (First/Last Name, Employed By)


Father's Primary Phone: *
May we text?*
No
Yes

Is there anything I need to know that will help me teach your child better, i.e. physical limitations, learning disabilities, etc:
Photo Permission
Do you authorize permission for your child's photo to be used:*
No
Yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Photography/Video Release: Participants involved in any activities offered by Swim With Gina, Gina Hester or any staff members may be photographed or videotaped during activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Swim With Gina website or in any editorial, promotional or advertising material produced and/or published by Gina Hester.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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