To register for the January 21 STR Clinics in Tallahassee, print out this form and fax back to 866-469-3614.

 

Starts and Turns Clinic, Freestyle Clinic, Aquanex+Video Analysis Clinic

Registration and Participation Release Form

 

DATE:                   Sunday, January 21, 2007

TIME:                    11:30am-1:00pm Starts and Turns Clinic; 1:00-3:00pm Freestyle Clinic; 3:00-4:30pm Aquanex+Video Analysis Clinic

CLINICIAN:            Rod Havriluk, Ph.D.

FORMAT:              The Starts and Turns Clinic is a 90 min pool session. The Freestyle Clinic includes a classroom and pool sessions. The  Aquanex+Video Analysis Clinic includes a pool testing session, a classroom feedback session, and a personal CD.

LOCATION:            Leach Center on the FSU campus, Tallahassee, FL.

FEE:                     The starts and turns clinic is $69. The freestyle clinic is $49. The fee for the Analysis Clinic depends on the number of strokes analyzed: 1 stroke - $49, 2 - $59, 3 - $69, all 4 - $79.

PROCEDURE:       Fill in this form and return to STR by Tuesday, January 16. Registrations received after that date will be accommodated as much as possible. Hand paddles are recommended for the Starts and Turns Clinic and the Freestyle Clinic.

QUESTIONS:         Sharon Kidd Loving: email (kidd@swimmingtechnology.com) or call (850-385-9803)

 

Please read carefully before signing. This is a release of liability and waiver of certain legal rights.

 

I, ___________________________, the enrolled participant and/or parent/guardian of the participant agree and understand that swimming is a hazardous activity. I recognize that there are risks inherent in the sport of swimming, including but not limited to, paralyzing injuries and death.

 The participant hereby agrees to participate in this program and hereby agrees to indemnify and hold harmless Swimming Technology Research, Inc. (“STR”), its officers, directors, instructors, consultants, agents, or subcontractors against any liability resulting from injury that may occur to the participant while participating in any STR activity. The participant also agrees to indemnify STR for any damages incurred arising from any claims, demand, action or cause of action by the participant.

 The participant authorizes any representative of STR to have the participant treated in any medical emergency during their participation in any STR program. Further, the participant and/or parent/guardian agree to pay all cost associated with medical care and transportation for the participant.

 I have noted on the back of this form any medical/health problems of which the staff should be aware.

 I have carefully read the above liability release and sign it with full knowledge of its contents and significance.

 

Signature (parent, if minor) __________________________________Date_____________

 

Participant name______________________________ Age ____ Height_____ Weight ____ Gender____

 

Home phone________________ Work phone_______________ E-mail___________________________

 

Clinic preference(s):    ___Starts & Turns      ___Freestyle      ___Aquanex+Video Analysis

 

Aquanex+Video Analysis Clinic - strokes to be tested:  ___Fly   ___Back   ___Breast   ___Free

 

Name as on credit card_______________________ Payment: ___check   ___credit card   ___gift cert #______

 

Street____________________________ City__________________ State______ Zip________

 

Credit card number __________________________ Exp_________