Camp Coyote Flats - Swim Lesson/Course Registration Form

Please provide the following contact information:

Please make check payable to “Camp Coyote Flats.” Before engaging in any physical activity, it is advisable to check with a physician

regarding any condition that may limit participation.

OFFICE USE ONLY: Paid $ Check#/Cash Date Rec’d by __________________________

Release and Waiver

Release - as part of the consideration for being allowed to participate in swim lessons/course or programs, the undersigned agrees that

neither Camp Coyote Flats any director, officer, employee, agent or representative of Camp Coyote Flats shall be liable for any loss,

damage injury or claim of an kind to person or property arising from or caused by participation by the undersigned in swim lessons

including without limitation any loss damage or claim arising from any accident involving the undersigned whether on or off the

Representatives property.

Waiver and Indemnification - The undersigned hereby waves all claims and demands against the representatives and each of them

for nay loss damage injury (including death) or claim of any kind arising from related to or caused by participation by the undersigned in

the activity and agrees to indemnify defend and hold harmless the representative from all loss liability costs and expenses

(including actual attorney fees) arising from or related to same.

This release and waiver has been carefully read by the undersigned and demands against the representatives and the contents of this

document are understood by the undersigned. This release and waiver shall be in effect for all swim activities in which I or my dependant

participates in throughout the entire calendar year. The undersigned freely executes this document.

In witness whereof, the undersigned has executed this release and waiver on the date shown below. I have read and understand the release

and waiver?

Yes No

Signature of applicant or Parent Legal Guardian:

Additional Comments: