1. sports
2. swimming

2015 Registration Kit
Swimming instruction for
pre-school to adult and
aquatic leadership courses
Registrations are received on-line OR in person in
the qplex Administration Office which is located
just off the indoor walking track.
20 Randy Jones Way, Quispamsis, NB |
506.848.5900 TEL
|
quispamsis@quispamsis.ca |
WWW.QUISPAMSIS.CA
Community Services Department
P.O. Box 21085, Quispamsis, NB E2E 4Z4
Telephone: 848-5900
Fax: 848-5910
________________________________________________________________________
Spring 2015
Dear Parent / Guardian:
Thank you for considering the Quispamsis Community Services Department Summer Swimming
Instruction Program for your child(ren) and/or yourself.
We are pleased to offer the Red Cross Pre-School, Swim Kids & Adult programs for you and your children
for the fifth summer at the qplex pool. In order to better accommodate the needs of our swimmers and
their families, we are offering a variety of swimming times and levels through our pool program. The pool
will commence swimming lessons on the 29th of June 2015. Classes have been predetermined but some
adjustments may be made as the program dates approach and registration numbers dictate. Information
on adult lessons and advanced/leadership courses are also offered in this kit.
Interested persons are invited to register on-line beginning at 8:30am on Monday, April 13th. If you are
unable to register on-line you may do so in person beginning on April 20th at the qplex Administration
Office. Office hours are Monday through Friday, 8:00 am – 4:30 pm .
If you have any questions or concerns regarding our recreation programs please feel welcome to speak
with one of our helpful pool staff or contact our office at 848-5900.
Sincerely,
Megan Lucas,
Program Director
2
Red Cross Pre-School & Swim Kids — Participant Registration form
Page 1 of 3
Name:
M/F
Age: (while at the pool)
Address:
Street
Birth Date:
City/Town
/
MM
DD
/
Postal Code
Family E-Mail: ____________________________
YYYY
Do you wish to be added to our Qmail list? Yes ___ No ___
Qmail is a FREE email service about community events.
If you/your child has had/does have any of the following, please check
Medical Information
o Asthma
o Frequent Colds
o Allergies to food (specify)
o Epilepsy
o Ear Trouble
o Allergies to medication
o Diabetes
o Sinus Trouble
o Physical disabilities
o Seizures
o Nosebleeds
o Intellectual disabilities
o Attention Deficit Disorder
ANY OTHER Information about special conditions: (medication, precautions, etc.)
Parent Information
Mother
Home Phone
Work Phone
______
Address
Street
City/Town
Father
Home Phone
Postal Code
Work Phone _______
Address
Street
ALTERNATIVE CONTACT
City/Town
Postal Code
(in case parents can not be reached)
Name
Home Phone
Work Phone _______
Address
Street
City/Town
Postal Code
Authorization:
In permitting my child
to attend the swimming instruction offered by the Quispamsis Community
Services Department, I the undersigned permit my child to participate in the full range of activities and authorize the Swimming
Instructor Supervisor and his/her appointees in the event of an accident or illness affecting the above named swimmer to
authorize on my behalf all necessary treatment procedures therein as he/she may deem essential for the care and well-being of
said child. Such action is to be undertaken only when immediate contact with the undersigned cannot be made. I understand
that the pictures taken during swimming classes may be used for promotion.
DATED:
, 20
SIGNED:
_______________
Parent or Guardian
The personal information gathered on this form is voluntarily provided by individuals. If provided, the information will be used or disclosed
only for the purposes for which it was collected in accordance with the New Brunswick Right to Information and Protection of Privacy Act. If
you have any questions regarding the collection and use of this information, please contact Megan Lucas, Program Director at (506) 849-5773.
3
Red Cross Pre-School & Swim Kids — Participant Registration form
Registrations:
Please check
Red Cross Swim Program Level Entering:
Registration For:
1
O
6
O
2
O
7
O
___ 9:30 am
___ 11:30 am
3
O
8
O
___ 10:00 am
___ 6:00 pm
___ 10:30 am
___ 6:30 pm
___ 11:00 am
___ 7:00 pm
4
O
9
O
5
O
10
O

Page 2 of 3
June 29 – July 10* O
for ages 5 years and up
July 13 – 24
Last Level Completed: _________
ADULT/PRIVATE LESSONS:
Sessions 1-4, Various times
O
O
___ 9:30 am
___ 11:30 am
___ 10:00 am
___ 6:00 pm
___ 10:30 am
___ 6:30 pm
___ 11:00 am
___ 7:00 pm
Dependant on instructor availability
July 27 – Aug 7*
PRE-SCHOOL:
Sea Turtle* (24-36 mos)
O
Sea Otter (3 to 5 years)
O
___ 9:30 am
___ 11:30 am
___ 10:00 am
___ 6:00 pm
___ 10:30 am
___ 6:30 pm
___ 11:00 am
___ 7:00 pm
O
O
A minimum of 4 students and
a maximum of 8 are required
for most classes. Please refer
to level descriptions.
August 10 – 21 O
___ 9:30 am
___ 11:30 am
___ 10:00 am
___ 6:00 pm
___ 10:30 am
___ 6:30 pm
___ 11:00 am
___ 7:00 pm
Please return your completed forms and
fees to the qplex office or via mail to
P.O. Box 21085, Quispamsis, NB E2E
4Z4. Cheques should be made payable
to the Town of Quispamsis. Interact,
MasterCard, VISA, American Express,
and cash are all accepted as well.
As the programs often fill up very quickly we
recommend that you complete your
registration on-line at
www.qplex.quispamsis.ca when they will first
be received, beginning at 8:30am on Monday,
April 13th.
Salamander (3 to 5 years) O
Sunfish (3 to 6 years)
Register on-line at
www.qplex.quispamsis.ca beginning on
April 13th at 8:30am. Registrations will
be also be received in person in the
qplex administration office during
regular office hours (Monday – Friday,
8am-4:30pm) beginning on April 20th.
All registrations are processed on a first
-come first-served basis.
$ 60.00 / participant / session
(discounts available for qplex pool members)
Adult and private lessons ($15/half-hour) are
subject to instructor availability.
* Not on Holidays
Refunds issued only when medical excuses or employers notes provided.
FOR OFFICE USE ONLY
Date
Payment Form &
Amount
Receipt
Number
Clerk
Date
Payment Form &
Amount
Receipt
Clerk
Number
4
Red Cross Pre-School & Swim Kids — Participant Registration form
Page 3 of 3
Parent’s or Guardian’s Additional Release and Indemnification
(Must be completed for participants under the age of 19)
This is to certify that I, as parent / guardian with legal responsibility for____________________ do consent and
agree to his / her participation in the swimming instruction program. In consideration of my child being permitted to
participate in the said program, I hereby release The town of Quispamsis from any and all claims or causes of
action I may have in connection with my child’s participation in this activity and agree to indemnify and hold
harmless The town of Quispamsis from any and all claims which are brought by, or on behalf of, my child, and
which are in any way connected with his / her participation in the said program.
I HAVE READ THE ABOVE RELEASE OF LIABILITY AND INDEMNIFICATION. I FULLY
UNDERSTAND AND AGREE TO BE BOUND BY THE TERMS.
Parent / Guardian’s Signature:
Date:
_________________________
______________
Release of Liability
(Must be completed by participants 19 years of age and older)
I acknowledge that there is risk of injury from the activities involved in this program and while particular rules,
equipment, and personal discipline may reduce the risk, the risk for injury and even death or paralysis does exist. I
knowingly and freely assume all such risks, both known and unknown.
In consideration of The town of Quispamsis permitting me to participate in the
program, I hereby release and discharge The town of Quispamsis from any and all claims, demands or causes of
action which are in any way connected with my participation in this activity and with respect to any and all injury,
disability, death, or loss or damage to persons or property arising from such participation.
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby indemnify and hold
harmless The town of Quispamsis from any and all liabilities incident to participation in this program.
I HAVE READ THIS RELEASE OF LIABILITY AND FULLY UNDERSTAND AND AGREE TO BE BOUND
BY ITS TERMS.
Signature of Participant:
(Participant who is over the age of 19)
Participant’s Name (Please Print):
Date:
5
Session 1: June 29-July 10 (M-F) - no classes on July 1st, Public Swim 12:00noon-3:30pm and 4:00pm--7:30 pm
l
Leisure Pool
Leisure Pool
Leisure Pool
Jr Olympic Pool
Jr Olympic Pool
9:30-10:00am
Level 1
Level 2
Level 5
Level 9/10 Split
10:00-10:30am
Sunfish
Sea Otter
Level 4
Level 7/8 Split
10:30-11:00am
Salamander
Sea Otter
Level 3
Level 6
11:00-11:30am
YM/YWCA
YM/YWCA
Bronze Star
Bronze Star
11:30-12:00 noon
YM/YWCA
YM/YWCA
Bronze Star
Bronze Star
6:00-6:30pm
Salamander
Sea Turtle
Level 3
Level 4
6:30-7:00pm
Sea Otter
Level 1
Level 5
Level 3
7:00-7:30pm
Level 1
Level 2
Level 6
Level 7/8 Split
Session 2: July 13-24 (M-F) Leisure Pool
Leisure Pool
Leisure Pool
Jr Olympic Pool
Jr Olympic Pool
9:30-10:00am
Sea Otter
Level 2
Salamander
Level 6
10:00-10:30am
Level 1
Sea Otter
Salamander
Level 5
10:30-11:00am
Sunfish
Sea Turtle
Level 3
Level 4
11:00-11:30am
YM/YWCA
YM/YWCA
Bronze Medallion*
Bronze Medallion*
11:30-12:00 noon
YM/YWCA
YM/YWCA
Bronze Medallion*
Bronze Medallion*
6:00-6:30pm
Salamander
Sunfish
Level 3
Level 4
6:30-7:00pm
Sea Otter
Level 2
Level 5
Level 6
7:00-7:30pm
Level 2
Level 1
Level 9/10 Split
Level 7/8 Split
Session 3: July 27-Aug 7 (M-F) - no classes on August 3rd, Public Swim 12:00noon-3:30pm and 4:00pm--7:30 pm
l
Leisure Pool
Leisure Pool
Leisure Pool
Jr Olympic Pool
Jr Olympic Pool
9:30-10:00am
Level 1
Level 2
Level 5
Level 9/10 Split
10:00-10:30am
Sunfish
Sea Otter
Level 4
Level 7/8 Split
10:30-11:00am
Sea Otter
Salamander
Level 3
Level 6
11:00-11:30am
YM/YWCA
YM/YWCA
Bronze Cross*
Bronze Cross*
11:30-12:00 noon
YM/YWCA
YM/YWCA
Bronze Cross*
Bronze Cross*
6:00-6:30pm
Sea Otter
Sea Turtle
Level 3
Level 4
6:30-7:00pm
Salamander
Level 1
Level 4
Level 6
7:00-7:30pm
Level 1
Level 2
Level 5
Level 7/8 Split
Session 4: Aug 10-21 (M-F) Leisure Pool
Leisure Pool
Leisure Pool
Jr Olympic Pool
Level 5
Jr Olympic Pool
9:30-10:00am
Level 1
Level 2
10:00-10:30am
Sea Turtle
Salamander
Sea Otter
Level 4
10:30-11:00am
Salamander
Sea Otter
Level 1
Level 3
11:00-11:30am
YM/YWCA
YM/YWCA
NLS & Pool Core*
NLS & Pool Core*
11:30-12:00 noon
YM/YWCA
YM/YWCA
NLS & Pool Core*
NLS & Pool Core*
6:00-6:30pm
Sea Otter
Sunfish
Level 3
Level 4
6:30-7:00pm
Salamander
Level 2
7:00-7:30 pm
Level 2
Level 1
Sea Otter
*Exams for Bronze Medallion & Cross and the NLS Course will be held at another time
Level 9/10 Split
Level 6
Level 5
Level 7/8 Split
6
Welcome to Red Cross Swim Preschool
Congratulations on choosing Canada’s largest and most
recognized swimming and water safety program. While providing a
positive learning experience, Red Cross Swim Preschool sets the
foundation for a lifetime of swimming and fitness.
Maximum of 5 students/class
What do Sea Turtles learn?
What do Salamanders learn?
Get ready to jump right in!
Jump on in!
Sea Turtle is a transitional level where the
preschooler is being prepared to be transferred
from the care of the parent to the instructor.
Here each student learns, through games and
songs, the basics of front swim, kicking, breath
control and jumping into chest deep water.
In Salamander swimmers learn to swim 2m, improve
their float to unassisted for 5 seconds, and use PFDs.
Students also add kicking to their front & back glides
and jump into chest-deep water clothed & unassisted.
Ages 3 - 5 years.
Upon completion of level may advance to Swim Kids 1
Ages 24—36 months
Parental participation is required.
Upon level completion may advance to Sea Otters.
Students must be able to comfortably submerge their
whole head before starting salamanders.
What do Sea Otters learn?
What do Sunfish learn?
Jump on in!
Jump right in!
This is the first level for new swimmers who can
spend 30 minutes without their caregivers.
Swimmers work on front and back floats and
Assisted glides, kicking on front with buoyant
object, and will be able to swim 1 meter upon
completion of this level. Some skills require
wearing clothing.
Upon level completion student may advance to
Swim Kids 1.
Children must be able to spend 30 minutes in the
water without their caregivers. Ages 3 - 5 years.
Using games and activities Sunfish students learn to
swim 5 meters, increase their distance using buoyant
objects, increase glides with kick, develop roll-over
glide, side glide and front swim. Safety skills include
deep-water skills and use a Personal Flotation Device
(PFD). Some skills require being clothed.
Ages 3-6 years.
Upon completion student may advance to Swim Kids 2
Parents and caregivers: keep your swimmer afloat! Even when you’re not in the water, you play an essential role in the Red Cross Swim
Preschool Program. Your enthusiasm and encouragement can make your child’s swim lessons a fun and rewarding experience.
Here’s how you can help: Understand that the physical abilities of children vary greatly, resulting in development at different rates. Avoid
putting pressure on achievement; encourage your child to enjoy swim lessons and take pride in personal success. Praise your child for his or
her effort and recognize newly acquired skills. Success tips for your pre-schooler: Bring a healthy snack and drink for your child. Kids
are often hungry and tired after a lesson. If your child misses a lesson, talk with the Instructor. The Instructor may suggest skills to work on
during a family swim. Put a light, close-fitting t-shirt on your child if you think he or she may become cold during the half-hour class.
7
Program Content
Red Cross Swim Kids – Level 1
Swimming
Fitness Activities
Breathing: rhythmic breathing wearing
clothes
Kicking drills: flutter kick,
10 m (assisted)
Floats:
Front float and recovery 3 sec.
Back float and recovery 3 sec.
Rollover floats 6 sec. (assisted)
Glides:
Front glide 3 sec.
Front glide with kick 5 sec.
Back glide 3 sec.
Back glide with kick 5 sec.
Rollover glides 6 sec. (assisted)
Distance swim: 5 m
Skills and Water Safety
Site orientation and supervision
EMS
Shallow water entries/exits wearing clothes
Submerge head
Exhale through mouth and/or nose
Max 6 / class
Red Cross Swim Kids – Level 2
Swimming
Fitness Activities
Breathing: rhythmic breathing, 10 times, 2 ways
Floats:
Kicking drills: flutter
kick, 15 m (assisted)
Distance swim:
Front float, 5 sec.
10 m
Back float, 5 sec.
Skills and Water Safety
Site rules
Intro to PFD/Lifejacket wearing clothes
Weight transfer - shallow water
Deep water activities (assisted)
Community Hazards Awareness
Glides:
Front glide with flutter kick
Back glide with flutter kick wearing clothes
Side glide with flutter kick, 3 m (assisted)
Max 6 / class
Rollover glide with flutter kick, 6 sec.
Red Cross Swim Kids – Level 3
Swimming
Fitness Activities
Skills and Water Safety
Breathing: rhythmic breathing, 15 times
Kicking drills:
When and where to swim
Glides:
Flutter kick
Weight transfer, shallow water
Front glide with flutter kick
Deep end floats, 5 sec.
Back glide with flutter kick wearing clothes
Distance swim:
Change direction, deep water
Side glide with flutter kick, 5 sec.
15 m
Surface support, 20 sec., deep water
Front glide/side glide combo
Sitting dive
Front Crawl
PFDs, Deep Water Wearing Clothes
Max 6 / class
Community Hazards Awareness
8
Red Cross Swim Kids – Level 4
Swimming
Fitness Activities
Breathing: rhythmic breathing, 15 times (Front
Crawl Specific)
Kicking drills: Flutter kick
drill on back
Self-safety
Skills and Water Safety
Glides:
Distance swim:
Self-safety – safe diving
Front glide/side glide combo wearing clothes
25 m
Disorientating entries
Show how to contact EMS
Back glide and kick and shoulder roll
Kneeling dive
Max 6 / class
Front Crawl
Surface support, deep water, 45 sec. clothed
Red Cross Swim Kids – Level 5
Swimming
Fitness Activities
Skills and Water Safety
Rhythmic breathing, 15 times, 2 ways
Kicking drills:
How to be a safe boater
Front crawl wearing clothes
dolphin kick drill
Staying warm
Back crawl
Distance swim:
Intro to whip kick on back
50 m
Cold water HELP/HUDDLE
Intro to sculling, shallow water
Tread water, 1 min.
Stride dive
Max 8 / class
Disorienting entries wearing clothes
Red Cross Swim Kids – Level 6
Swimming
Front crawl,
Fitness Activities
Skills and Water Safety
Kicking drills:
Causes of boating incidents
Back crawl
Back crawl, 25m wearing
clothes
Elementary back stroke
When and where to go on ice
Distance swim:
Victim recognition and simulation
75 m
Throwing assist without a line
Head-first sculling on back, 5 m
Max 8 / class
Tread water, deep water, 1:30min. clothed
Front dive
Red Cross Swim Kids – Level 7
Swimming
Front crawl, 50 m (in one lesson)
Back crawl, 50 m (in one lesson)
Elementary back stroke, 25m clothed
Front scull
Whip kick on front, arms extended
Fitness Activities
Activity: eggbeater/tread
water stationary, 3 min.
Distance swim:
150 m
Max 10 / class
Skills and Water Safety
Partial and complete airway obstruction
Chocking rescue – conscious person
Throwing assist with a line
Reaching assist with an aid
Head-first sculling on back, 10 m
Stride Entry wearing clothes
Community Hazards Awareness
9
Red Cross Swim Kids – Level 8
Swimming
Fitness Activities
Skills and Water Safety
Front crawl, 75 m
Activity: egg beater/tread
Hypothermia
Back crawl, 75 m
water, 3 min. clothed
Dangers on open water
Kicking Drill:
Elementary back stroke, 50 m
Rescue breathing, adult and child
Dolphin kick drills
Breast stroke
Feet-first surface dive wearing clothes
Distance swim: 300 m
Stride entry
Max 10 / class
Red Cross Swim Kids – Level 9
Swimming
Fitness Activities
Skills and Water Safety
Front crawl, 100 m
Activities:
Wise choices – peer influence
Back crawl, 100 m
Travelling legs, only 3 min.
Complications of rescue breathing
Elementary back stroke, 50 m
Combo of stroke drills
Boating regulations
Breast stroke, 25 m wearing clothes
Distance swim: 400 m
Self-rescue – fallen through ice wearing clothes
Max 10 / class
Head-first surface dive
Standing shallow dive
Red Cross Swim Kids – Level 10
Swimming
Fitness Activities
Kicking drills: dolphin kick
Front crawl, 100 m
(vertical)
Back crawl, 100 m
sidestroke
Statistically Speaking: Drowning
Distance swim: 500 m
Breast stroke, 50 m
Sun smart
Ice rescue from safe zone
Strokes:
Elementary back stroke, 50 m
Skills and Water Safety
Side stroke, 25m wearing clothes
Max 10 / class
Next steps
Head/ feet first surface dive with underwater swim 2 m
wearing clothes
Adult Instruction - Red Cross Swim Basics 1
This course is offered to those adults who are true beginners. It is an introduction to swimming with a focus on front swim. During
the two-week session students will learn the following through the use of standard instruction, games, and more. Here’s your
chance to finally learn how to swim.
Breath control
Various glides with flutter kick
Shallow water entries and exits
Self-Safety & Safe Diving
Various floats
Skills in chest-deep water
PFDs and rescues with aids
...and more
10
In partnership with
we are pleased to offer you
Bronze Star
Bronze Medallion
WHEN:
WHEN: Monday through Friday
Monday through Friday
11:00 am – 12:00 pm*
10:00 am – 12:00 pm*
June 29 – July 10 (not July 1)
July 13 – July 24
WHERE: qplex pool
WHERE: qplex pool
FEE:
AGE:
FEE:
$115.00 (HST incl.) / student
AGE:
Have Bronze Star or 13 and older
$50.00 (HST incl.) / student
Have Swim Kids Level 10
REGISTRATION DEADLINE: July 7th
REGISTRATION DEADLINE: June 23rd
SUPPLIES: Additional ($35 for book)
SUPPLIES: Included
This program has a pre-requisite requirement
of Red Cross Swim Kids Level 10.
Bronze Cross
WHEN:
* 3-hour exam will be at another time
This program has a pre-requisite requirement of
Red Cross Swim Level 10 or Bronze Star.
Monday through Friday
10:00 am – 12:00 pm*
July 27 – August 7 (not Aug 3)
WHERE: qplex pool
FEE:
$115.00 (HST incl.) / student
AGE:
Have Bronze Medallion
Classes will be dependant on registration numbers – a minimum of 6 students is
required. Due to the restriction of numbers, post-dated cheques are the preferred
method of payment (in case a course does not operate due to low registration numbers).
Please make cheques payable to: Town of Quispamsis.
NLS CORE & Pool Course
WHEN: August 9—14, 2015 (tentative)
Various Hours Between: 9:00 am—9:00 pm
REGISTRATION DEADLINE: July 21st
SUPPLIES: Book is the same as Medallion,
therefore no charge
* 3-hour exam will be at another time
This program has a pre-requisite requirement of
Bronze Medallion.
WHERE: qplex pool
FEE:
$210 full, $65 recert (hst included)
AGE:
16 years and older
REGISTRATION DEADLINE: July 30th
Minimum of 9 registrants required.
Registration forms are located on pages 13 & 14.
11
Aquatic Leadership Course Descriptions
Bronze Star
This Lifesaving Society course is designed to help prepare candidates for the world of
lifeguarding. Bronze Star training emphasizes rescue skills and lifesaving fitness.
Bronze Star is designed to deliver high-performance training for skilled preteens. The
first level of our Bronze medal family, Bronze Star is excellent preparation for success in
Bronze Medallion.
Bronze Medallion
This course covers the basics of self rescue and the rescue of others. It is a prerequisite
to the Bronze Cross course. Swim Kids Level 10 or Bronze Star is a recommended
prerequisite.
Bronze Cross
Bronze Cross is the more advanced lifesaving course and is recommended to persons
interested in pursuing a lifeguarding career. Spinal cord management, rescue of
submerged victims and First Aid are major components of the program. Bronze Cross is
a prerequisite to the National Lifeguard Service Award.
NLS Pool & Core
National Lifeguard Service (NLS) training is designed to develop the basic lifeguarding
skills, principles and decision-making processes which will assist the lifeguard to
evaluate and adapt to different aquatic facilities and emergencies. This NLS Pool &
Core course has prerequisites of minimum age of 16 years and Bronze Cross.
12
Aquatic Leadership Courses (Bronze Family and NLS Pool & CORE) - Participant Registration Form, Page 1 of 2
Name:
Age: (while at the pool)
M/F
Address:
Street
Birth Date:
City/Town
/
MM
DD
Postal Code
/
Family E-Mail: ____________________________
YYYY
Do you wish to be added to our Qmail list? Yes ___ No ___
Medical Information
Qmail is a FREE email service about community events.
If your child has had/does have any of the following, please check
o Asthma
o Frequent Colds
o Allergies to food (specify)
________
o Epilepsy
o Ear Trouble
o Allergies to medication
________
o Diabetes
o Sinus Trouble
o Physical disabilities
o Seizures
o Nosebleeds
o Intellectual disabilities
o Attention Deficit Disorder
ANY OTHER Information about special conditions: (medication, precautions, etc.)
Parent Information
Mother
Home Phone
Work Phone _____________
Address
Street
City/Town
Father
Home Phone
Postal Code
Work Phone _______
Address
Street
ALTERNATIVE CONTACT
City/Town
Postal Code
(in case parents can not be reached)
Name
Home Phone
Work Phone _______
Address
Street
City/Town
Postal Code
Authorization:
In permitting my child
to attend the swimming instruction offered by the Quispamsis Community
Services Department, I the undersigned permit my child to participate in the full range of activities and authorize the Swimming
Instructor Supervisor and his/her appointees in the event of an accident or illness affecting the above named swimmer to
authorize on my behalf all necessary treatment procedures therein as he/she may deem essential for the care and well-being of
said child. Such action is to be undertaken only when immediate contact with the undersigned cannot be made. I understand
that the pictures taken during swimming classes may be used for promotion.
DATED:
, 20
SIGNED:
_______________
Parent or Guardian
The personal information gathered on this form is voluntarily provided by individuals. If provided, the information will be used or disclosed
only for the purposes for which it was collected in accordance with the New Brunswick Right to Information and Protection of Privacy Act. If
you have any questions regarding the collection and use of this information, please contact Megan Lucas, Program Director at (506) 849-5773.
13
Aquatic Leadership Courses (Bronze Family and NLS Pool & CORE) - Participant Registration Form, Page 2 of 2
Please indicate the course you / your child is registering for:
• __ Bronze Star
__ Bronze Medallion
__ Bronze Cross
__ NLS Pool & CORE
NLS Registrants must: ~ Be 16 years of age or older. ~ Be able to perform egg beater kick and keep forearms out
of water for at least 2 minutes. ~ Know their first aid and be able to perform as well, with no hesitation. ~ Bring
photocopies of their cards for date of birth, first aid and Bronze Cross.
NLS Recert Registrants must: ~ Bring their previous pool options card.
Refunds issued only when medical excuses or employers notes provided.
FOR OFFICE USE ONLY
Date
Payment Form & Amount
Receipt #
Clerk
Date
Payment Form & Amount
Receipt #
Clerk
Parent’s or Guardian’s Additional Release and Indemnification
(Must be completed for participants under the age of 19)
This is to certify that I, as parent / guardian with legal responsibility for____________________ do consent and agree to his /
her participation in the swimming instruction program. In consideration of my child being permitted to participate in the said
program, I hereby release The town of Quispamsis from any and all claims or causes of action I may have in connection with
my child’s participation in this activity and agree to indemnify and hold harmless The town of Quispamsis from any and all
claims which are brought by, or on behalf of, my child, and which are in any way connected with his / her participation in the
said program.
I HAVE READ THE ABOVE RELEASE OF LIABILITY AND INDEMNIFICATION. I FULLY UNDERSTAND AND AGREE TO
BE BOUND BY THE TERMS.
Parent / Guardian’s Signature:
Date:
_________________________
______________
Release of Liability
(Must be completed by participants 19 years of age and older)
I acknowledge that there is risk of injury from the activities involved in this program and while particular rules, equipment, and
personal discipline may reduce the risk, the risk for injury and even death or paralysis does exist. I knowingly and freely
assume all such risks, both known and unknown.
In consideration of the town of Quispamsis permitting me to participate in the
program, I
hereby release and discharge The town of Quispamsis from any and all claims, demands or causes of action which are in any
way connected with my participation in this activity and with respect to any and all injury, disability, death, or loss or damage to
persons or property arising from such participation.
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby indemnify and hold harmless
The town of Quispamsis from any and all liabilities incident to participation in this program.
I HAVE READ THIS RELEASE OF LIABILITY AND FULLY UNDERSTAND AND AGREE TO BE BOUND BY ITS TERMS.
Signature of Participant:
Participant’s Name (Please Print):
(Participant who is over the age of 19)
______________ Date:
____
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