Application:
(Class Attending)
Please complete this form and re-
turn your completed application, along with your check for each applicant on the night of registration. (Make checks
payable to Pitt Johnstown) Call 814-269-2006 for additional information.
Participant Name Age of
Child
Level
NEW
Student?
Session
1 2 3
1.
2.
3.
4.
Parent Guardian/Adult student:
Home Phone:
Address:
Cell Phone:
City:
State
Zip
Pl
ease remember that the UPJ gym and weight room are for use by UPJ students, faculty and staff only. All aquatic center
rules and regulations must be followed.
The Center for Disease Control recommendations to protect yourself and your family against recreational water illnesses
include the three “PLEAs” for all swimmers to stop germs from causing illness at the pool.
1. Please do not swim if you have diarrhea. This is especially important for kids in diapers. You can spread germs in
the water and make other people sick.
2. Please do not swallow the pool water. In fact avoid getting water in your mouth.
3. Please practice good hygiene. Take a shower before swimming and wash your hands after using the toilet or changing
diapers. Germs on your body end up in the water.
Doe
s anyone from your family who is participating in the aquatic programs at UPJ have a serious or potentially
serious medical condition? (Yes) ____
(No)Please specify below:
In case of emergency, please notify:
Na
me:
P
hone:
Name:
P
hone:
The Swimmer’s Ear
University of Pittsburgh at Johnstown/Zamias Aquatic Center
2019
DATE REC’D
AMT. REC’D
CASH/CHECK
Please complete the Application and Release.
These forms must be completed and on file
before the students can participate.
University of Pittsburgh at Johnstown
Zamias Aquatic Center
RELEASE OF LIABILITY
This is a legally-binding release made by
(print full name)
to The University of Pittsburgh at Johnstown.
I/We agree to obey all staff members assigned to direct this program and to follow all rules and safety
procedures established by the American Red Cross and The University of Pittsburgh at Johnstown. I/We certify, that
to the best of my/our knowledge, my and my child’s current physical condition is satisfactory for participation in the
aquatic classes. I and my family are free of any health problems which would endanger my/our participation and
that I will inform the instructor should health conditions change at any time during participation in this program.
I/We fully recognize that there are dangers and risks to which I/we or my children may be exposed by
participating in the classes sponsored by The University of Pittsburgh at Johnstown during the 2019 aquatic classes.
Examples of these dangers and risks include but are not limited to: drowning, spinal injury, fractures, and head
injuries. I/We understand that the University does not require me/us to participate in this activity, but I/we want to
do so, despite the possible dangers and risks and despite this Release.
I/We therefore agree to assume and take on myself/ourselves all of the risks and responsibilities in any way
associated with this activity. In consideration of and return for the services, facilities and other things provided to
me by the University in this activity, I/we HEREBY RELEASE THE UNIVERSITY (and its trustees, employees and agents)
FROM ANY AND ALL LIABILITY, CLAIMS AND ACTIONS THAT MAY ARISE FROM INJURY OR HARM TO ME AND MY
FAMILY, FROM DEATH OR FROM DAMAGE TO MY/OUR PROPERTY, IN CONNECTION WITH THIS ACTIVITY. I/WE UN-
DERSTAND THAT THIS RELEASE COVERS LIABILITY, CLAIMS AND ACTIONS CAUSED ENTIRELY OR IN PART BY ANY ACTS
OR FAILURES TO ACT OF THE UNIVERSITY (or its trustees, employees or agents), INCLUDING BUT NOT LIMITED TO
NEGLIGENCE, MISTAKE OR FAILURE TO SUPERVISE BY THE UNIVERSITY.
I/We recognize that this Release means I/We are giving up, among other things, rights to sue the University
for injuries, damages or losses I/we may incur. I/We also understand that this Release binds my heirs, executors,
administrators and assigns, as well as myself/ourselves.
I/We have read this entire release, I fully understand it and agree to be legally bound by it.
Students Name: ______ READ CAREFULLY BEFORE SIGNING.
Phone #:
Releaser's Signature
Date
* Please remember, "if you have or have had diarrhea in the past two weeks, please do not use the pool".
click to sign
signature
click to edit
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