Mail to: Evergreen , Swim Lessons, CRC 210, Olympia, WA 98505, or
Leisure Education, CRC 210, Olympia, WA 98505

Full payment must accompany registration. Date: ___________________________________________
Name: _______________________________________________________(Parents name if registering child)
Street Address: _________________________________________________________________
City: _______________________________________________ State:_____ Zip: _____________
Day Phone:_____________________________ Night Phone: _____________________________
Emergency Phone:_____________________________ Email:_____________________________
Evergreen Banner Number (to be completed by Evergreen students, faculty, and staff only): _____________________________________________________

Let us help you by telling us how you heard about our activities:

Athletic and Recreation Guide _____ Swim Brochure _____ Online _____
Flier _____ Word of Mouth _____ Other: ____________________

I, the undersigned, hereby acknowledge that I am fully aware of and understand the risks involved in participating in high risk activities through some of the recreational programs of The Evergreen State College. I understand it is recommended that I/my child have a medical insurance policy in effect during my participation. (Students pursuing an Evergreen degree and enrolled for eight (8) credit hours or more are encouraged to enroll in the college's accident /medical insurance program). I agree to inform the instructor of any special needs, physical handicaps or impairments which might inhibit my/my child's participation in these activities. I give The Evergreen State College permission to publish in print, electronic, or video format the likeness or image of myself/my child. I release all claims against the College with respect to copyright ownership and publication including any claim for compensation related to use of the materials.

I give The Evergreen State College permission to publish in print, electronic, or video format the likeness or image of myself/my child. I release all claims against the College with respect to copyright ownership and publication including any claim for compensation related to use of the materials.

Signature:___________________________________________Date:_________________________________________