Percy Walker Pool Release Form

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This form needs to be filled out before participating at The Percy Walker Pool

Email *

Party Name: *

Swimmer's Name: *

Gender *

Male

Female

Required

Address *

Phone Number *

Emergency Contact Name and Phone Number *

Date of Birth *

YYYY

Age *

IN CASE OF EMERENCY, PLEASE NOTIFY: please list name, relation to swimmer, and phone number *

Allergies or Physical Difficulties: *

Pool Policy: Any Non-swimmers MUST be accompanied by a responsible adult in the water. Floatation devices are NOT a substitute for an adult.

I/We the undersigned do authorize and permit said child/adult to participate in all athletic, recreational and aquatic activities without limitation conducted by the Town of Duxbury under its Recreation Director and the Percy Walker Pool. I/We assume all risk and hazards incidental to such participation including transportation to and from the activities; and I/We do hereby waive, release, absolve, indemnify and agree to hold harmless the organizers, sponsors, supervisors and participants from all claims for damages to persons which may result from any such activity by such child and/or adult.

By printing your name below, you are agreeing to the above statements.

Send me a copy of my responses.

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