In the event that my child(ren) requires medical attention, I hereby give full authority and
consent for Southampton Recreation Association (SRA here and after) and its coaches, staff
and volunteers to provide through a medical staff of its choice, customary medical attention,
transportation and emergency services as warranted. I hereby release the SRA coaches, staff
and volunteers from all claims that may arise from their good faith exercise of this authority.
 

Parent’s Signature	Print Name
Insurance Company	Policy Number
Physician	Phone Number
Emergency Contact	Phone # if you cannot be reached

In consideration of allowing me to participate in the SRA Clinic and/or on the SRA Swim Team,
I hereby release and hold harmless SRA and its officers, employees, volunteers and other participants of
and from, and do discharge and waive, any and all claims, demands, losses, damages and liabilities that
I may have or sustain arising out of my participation in this activity. I understand and appreciate that my
participation in the sport of swimming carries a risk of serious injury, including permanent paralysis or death.
I voluntarily recognize, accept and assume this risk. I recognize that SRA is a 501C(7) non-profit organization
that provides recreational programs for children, and that as a participant, I receive the benefits and bounty
of that charity.

Signature of Parent or Guardian on behalf of participant:
Relationship	Date