HOME BASE SWIM

RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND

INDEMNITY AGREEMENT

** BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS,

INCLUDING THE RIGHT TO SUE - PLEASE READ CAREFULLY **
--------------------------------------------Swimmers Name: _________________________________________
Address: _________________________________________
Date of Birth: ____________________
Parents or Legal Guardians Name: _____________________________
Telephone:________________________
E-Mail: __________________________

The above-named Swimmer is referred to as the Minor Participant.

------------------------------------------------TO: HOME BASE SWIM and its various instructors, including, without limitation, Greg Roberts, Jason
Sokolowski, Alex Sokolowski, Leah Vignale and Colin Ploeg (collectively, the Releasees).
I wish to have my child participate in Home Base Swim Swimming Lessons at______________________
(address of location at which lessons will be conducted).
Release and Indemnity
I, the undersigned hereby acknowledge that I am the parent or legal guardian of the Minor Participant
with full legal authority (and the corresponding duty) to care for the personal and interests of the Minor
Participant, or that I have been expressly authorized by the parent or legal guardian of the Minor
Participant to enter into this agreement with their knowledge and consent.
I have in my personal capacity and as parent or legal guardian of the Minor Participant, specifically
requested that the Releasees allow the Minor Participant to participate in Home Base Swim Swimming
Lessons, and that in consideration of the Releasees agreeing to my request, and other good and valuable
consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby, in my personal
capacity, and also as parent or legal guardian of the Minor Participant, RELEASE AND FOREVER
DISCHARGE the Releasees from all claims, damages, actions, or causes of action, arising from or which
may arise by reason of the use of the services and facilities by the Minor Participant as outlined above,
and from all claims or demands whatsoever, whether in law or in equity which I individually and/or as
parent and/or legal guardian, or my heirs, executors, administrators and assigns can, shall or may have
because of such use.

And in further consideration of the above-noted consideration, I agree to be responsible for the behaviour
of the above-named Minor Participant while participating in and using the services and facilities of the
Facility and I further covenant to FULLY INDEMNIFY AND SAVE HARMLESS the Releasees and their
successors and assigns: 1) against all financial obligations in connection with the Minor Participants use
of the services and facilities including actions, damages, debts, accounts, claims and demands which may
be brought against any of them by or on behalf of the above-named Minor Participant because of such
participation or use; and 2) against any actions, damages, debts, accounts, claims and demands that the
Releasees may suffer in the event that any finding is made that I was not capable or duly authorized to
grant this Release on behalf of of the Minor Participant.
Assumption of Risks
I am aware that swimming involves strenuous physical activity including muscle strength, endurance, and
cardiovascular exertion.
I acknowledge that swimming may be new to my child, and will challenge and possibly exceed his or her
level of ability. While participating in swimming my child may also be exposed to the negligent acts of
the Releasees and other participants. The conditions and injuries my child may develop as a result of
participating in swimming include muscle strains, muscle pulls, muscle tears, cuts, contusions, broken
bones, heat prostration, paralysis, drowning and other illnesses and soreness, including death. I freely and
willingly accept and fully assume all such risks, dangers and hazards and the possibility of personal injury
to my child, or his or her death, property damage or loss resulting from them.
All Home Base Swim instructors have certified training in emergency first aid. In case of emergency, I
authorize Home Base Swim instructors and/or trained first responders to provide treatment as necessary.
Confirmation of Physical Condition
I hereby affirm that my child is in good physical condition and does not suffer from any known disability
or condition which would prevent or limit his or her participation in swimming lessons.
Verification of Adequate Insurance
In the case where lessons are conducted at my home, I verify and confirm that I have homeowners
insurance that includes comprehensive personal liability coverage and voluntary medical coverage
including the use of a pool for recreational purposes.
Acknowledgements
I HAVE READ AND UNDERSTOOD THIS AGREEMENT PRIOR TO SIGNING IT, AND I AM
AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS
WHICH I OR MY HEIRS, NEXT-OF-KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY
HAVE AGAINST THE RELEASEES.

Signed this ___ day of _____________, 2014.

_______________________________
Witness

__________________________________
Signature of Parent/Legal Guardian