Summer Adult Session ($50)
Summer Adult Trial Class ($15)
Please use XX/XX/XXXX format
Please put a phone number you would like to share with other families in our team-only area. Leave blank if you choose not to share a number.
Emergency Contact Phone
Emergency Contact Relationship
Waiver and Release of Liability
In consideration of being allowed to participate in any way in U.S. Synchronized Swimming ("USA Synchro") events,
activities, or programs, I acknowledge and agree that:
1. I understand that I or (if the participant is a minor) my child or ward, will be engaging in travel and activities that
involve the risk of serious injury, including permanent disability and death, severe social and economic losses and
other loss including damage to property.
2. I knowingly and freely assume all such risks.
3. I, for myself, or (if the participant is a minor) my child or ward, and on behalf of my and their heirs and assigns, release, waive, discharge and covenant not to sue U.S. Synchronized Swimming, Inc., its officers, agents, employees, and sponsors as well as its
affiliate clubs, from any and all liability for any and all claims, demands, losses or damages on account of injury,
including death and damage to property, whether caused by negligence or otherwise. If the participant is a minor, I consent to the collection of personal information regarding my child or ward through
USA Synchro’s online Membership Management System, as "personal information" is defined in USA Synchro's
On Line Privacy Statement. PLEASE TYPE YOUR NAME ABOVE AS YOUR DIGITAL SIGNATURE.
Photo and Video Release
I hereby grant permission to the rights of my or (if the participant is a minor) my child or ward’s image, likeness and sound of my (or if the participant is a minor, her or his) voice as recorded on audio or videotape without payment or any other consideration. I understand that my (or if the participant is a minor, her or his)image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my (or if the participant is a minor, her or his) likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my (or if the participant is a minor, her or his) image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.
I allow Mad City Aqua Stars to use any pictures/video taken of me (or if the participant is a minor, my minor child) in publicity, including, but not limited to:
• Video, photo albums, newsletters, bulletin boards, fliers, and any other publications/publicity material for Mad City Aqua Stars.
● Educational and informational presentations including video and online courses
● Social media outlets and channels including, but not limited to Facebook, Twitter, MCAS webpage, and YouTube
By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of my participation in Mad City Aqua Stars and related events only.
By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational and promotional purposes. PLEASE TYPE YOUR NAME ABOVE AS YOUR DIGITAL SIGNATURE.
How did you hear about us?
For new swimmers, please let us know how you heard about us. You may select more than one response.