Thrive After School Swim Program

Urgent Care Fort Dodge

04 Patients
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Swim Registration

Please read carefully before completing the form below.

Before starting any exercise program, parents should have their child examined by a physician.  Upon allowing my child to participate in the after school swimming program, it is assumed that in the case of a parent's or guardian's absence or unavailability, the REC staff is authorized to arrange for any medical treatment that is considered necessary for the minor child enrolled in the program. 

I grant my child permission to participate in Thrive's After School Swimming Program at the REC.  By signing this consent form, I understand that swimming poses potential hazards as well as transportation to the REC to participate in the swimming program.  Knowing this, I hereby release Trinity Regional Medical Center and the REC's staff from any and all blame should injury occur or property be stolen/damaged while my child participates in this program. 

I understand my child is to be picked up by 4:25 pm as there will be no supervision after this time.  All participants in the program must make a commitment to pick up your child on time.  If there is an extraordinary circumstance, your child must wait at the front desk of the REC.

Child's School Child's Name Grade Age Date of birth Parent/Guardian Name Street Address City Zip Code Home phone Alternative Phone Number Emergency Contact Phone Number Relation to Child Has this child had swim lessons before? If so, what was the last level completed?Does your child have a fear or water or other concerns we should be aware of?Medical/Special Information (allergies, injuries, etc.)Parent/Gaurdian Signature Today's Date Email Address