American Red Cross Learn-to-Swim Program
Level: (circle) PCA 1
Level
PCA 2
1
2
Preschool 1
3
4
5
Preschool 2
6
Preschool 3
Adult
Month: (circle) Jan Feb March April May June July Aug Sept Oct Nov Dec
Dates: (from) ______________
(to) _______________
Time: (start) _____________
(end) ______________
Cost:
MTSU Student MTSU Employee
Guest
30 minute classes (PCA Level 1 or 2 only)
$30.00
$45.00
$55.00
50 minute classes (Preschool 1-3), Levels 1-6, Adult
$60.00
$75.00
$85.00
Registration: Sign up and pay in the Campus Recreation offices by 12:00 noon of the Friday before
class begins. The Campus Recreation office is open from Monday thru Friday from
7:30 a.m. – 5:00 p.m. Please bring license plate number so you can be issued a temporary
parking permit.
Payment: Campus Recreation accepts cash, check, Raider Funds and all major credit cards as payment. Please
make checks payable to MTSU Campus Recreation.
Refund Policy: Full refund up to two weeks prior to class. 50% refund between one and two weeks
prior to class. NO REFUND less than one week prior to class.
Participant’s Name: _______________________________________
Age: ____________________
Parent/Guardian’s Name: ______________________________________________________________
Address: ___________________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Home Phone: ___________________________
Cell Phone: ___________________________
Email Address: ______________________________________________________________________
How did you hear about our Learn-to-Swim program?
___Website
___Flyer
___Past Participant
___Newspaper
___Word of Mouth
Other _______________________________________________________________
For Office Use Only
Circle One:
Student
Faculty/Staff
Guest
Amount Paid: __________ Date: ___________Payment Type: _________ Receipt: _________ Attendant: _______
HOLD HARMLESS AGREEMENT
I PROMISE NOT TO SUE MIDDLE TENNESSEE STATE UNIVERSITY FOR ANY INJURIES OCCURRING WHILE I AM PARTICIPATING IN THIS
ACTIVITY:
(1) In consideration for receiving permission to participate in ___Swim-Lessons___ (Thereinafter referred to as “activity”). I release and covenant not to
sue Middle Tennessee State University, the Board of Regents of the State University and Community College System of Tennessee, the State of Tennessee,
and all employees and agents of these parties (hereinafter referred to as (“releases”) from all claims related to any loss that may be sustained by me,
including loss of life, or to any property belonging to me, whether caused by the negligence of the releases or otherwise, while participating in this activity,
or while on the premises where this activity is being conducted.
(2) I AM AWARE OF THE RISKS OF CHOOSING TO PARTICIPATE IN THIS ACTIVITY, I ACCEPT RESPONSIBILITY FOR THESE RISKS:
The activity has been explained to me, including the risks involved in participating in this activity, and I understand these risks. These risks include injury,
illness, and death. I voluntarily choose to participate in this activity. I voluntarily assume full responsibility for any risks of loss, property damage or personal
injury, including death that may be sustained by me as a result of participating in this activity, whether caused by the negligence of the releases or otherwise.
(3) I WILL REIMBURSE MIDDLE TENNESSEE STATE UNIVERSITY FOR ANY COSTS THEY INCUR BECAUSE OF MY PARTICIPATION IN THIS
ACTIVITY:
I agree to indemnify the releases for any loss or costs, including medical bills, court costs and attorney’s fees, that they may incur due to my participation in
this activity, whether this loss is a result of the negligence of releases or otherwise.
(4) THIS AGREEMENT WILL ALSO PREVENT MY FAMILY FROM SUING MIDDLE TENNESSEE STATE UNIVERSITY:
It is my intent that this Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am
deceased. This agreement shall be deemed as a release and consent not to sue regarding any claims these parties may have against releases to my
participation in this activity, whether these claims arise out of the negligence of the releases or otherwise.
(5) THIS AGREEMENT SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF TENNESSEE.
In signing this Agreement, I acknowledge that I have read it and understand it, and that I sign it voluntarily.
Today’s Date: _____________________
Participant’s Date of Birth _________________
_______________________________________________________________________________
Signature of Participant (Parent or legal guardian if participant is under 18)
MODEL RELEASE FOR USE OF IMAGE
The undersigned irrevocably consents to and authorizes the use by MTSU Campus Recreation of the undersigned’s image, voice, and/or
likeness to video, photograph, publish, republish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute,
display, or otherwise use or reuse the undersigned’s image in connection with any promotional services in all markets, media or technology
now known or hereafter developed in the University’s produce or services as long as there is no intent to use it in a disparaging or
commercial manner. I understand that all such recordings, in whatever media, shall remain the property of the University. I hereby assign
any copyright or proprietary interest which I might assert to the University. The University may exercise any of these rights itself or through
any successors, transferees, licensees, distributors or other parties, commercial or non-profit. I hereby release the University from liability
for any violation of any personal or proprietary right I may have in connection with such use. The undersigned acknowledges receipt of
good and valuable consideration in exchange for this release, which is simply the opportunity to represent the university in its promotional
and advertising materials as described above.
Today’s Date: _____________________
Participant’s Date of Birth _________________
_______________________________________________________________________________
Signature of Participant (Parent or legal guardian if participant is under 18)