DYNAMO SWIM SCHOOL 770-772-6789 x18			Session:						Date:
			Time:
			Neighborhood:
Student Name:					Student Age:				Date of Birth:
Parent Name:					Phone:
Address:					Email:
City:				Zip:	Registration Fee:
Returning		New Student		Method of Payment:	A $10.00 registration fee is included in the
If Returning, date of last classes: ___________________				Cash Check	Class Price.
TOTAL AMOUNT PAID $ ______________________					Class Price $106.00		Credits or Fees + / -			Amount Paid this Class
WE DO NOT OFFER REFUNDS OR MAKE UP CLASSES					Recorded By			Date Paid
RELEASE AND INDEMIFICATION For and in consideration of the benefits to me from the use by me and/or my child(ren) of the facilities of Dynamo Parents Club, Inc. (Dynamo Swim School) and other good and valuable consideration, the undersigned, individually and for his/her heirs and personal representatives, hereby release Dynamo Parents Club, Inc. directors, officers, agents, swim team members and employees from any and all claims of any kind or nature whatsoever, arising out of the use by me and/or my child(ren) of said facilities. The undersigned, individually and for his/her heirs and personal representatives, further agree to indemnify, defend and forever hold harmless Dynamo Parents Club, Inc. and their directors, officers, agent, swim team members, and employees from any and all liability or loss whatsoever, (including any cost of defending claims) arising our of said use of said facilities.
(date) ________________	(print name) ___________________________________					(signature) ___________________________________