Competitive 3 Days
Competitive 2 Days
Summer Adult Class
Please use XX/XX/XXXX format
Parent 1 First Name
Parent 1 Last Name
Parent 1 Email
Parent 2 First Name
Parent 2 Last Name
Parent 2 Email
Parent 1 Cell
Parent 2 Cell
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.
FOR MINORS ONLY I have read the Know Your Concussion ABCs document (located on the Documents page) and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child or ward must be removed from practice/play if a concussion is suspected.
I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me.
I understand that my child or ward cannot return to practice/play untilproviding written clearance from an appropriate health care provider to his/her coach.
I understand the possible consequences of my child returning to practice/play too soon. 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.
USA Synchro Directory
No IF APPLICABLE I consent to my child or ward, as applicable, being listed in the USA Synchro Directory.
USA Synchro Email
No IF APPLICABLE I consent to my child or ward, as applicable, receiving from USA Synchro electronic
communications, such as an electronic newsletter, and information concerning programs and other opportunities
offered by USA Synchro.
USA Synchro Info.
No IF APPLICABLE I consent to allow USA Synchro to divulge information concerning my child or ward to third
Yes IF APPLICABLE I ACKNOWLEDGE THE FOLLOWING: Opt-Out of Collection of Personal Information: The parent or guardian has the option to agree to the collection and use of
the child's information without consenting to the disclosure of the information to third parties. USA Synchro shall not require
a child to disclose more information than is reasonably necessary to participate in an activity as a condition of participation.
The parent or guardian can review the child's personal information, ask to have it deleted and refuse to allow any further
collection or use of the child's information. USA Synchro will change the contents of any personal information of a child
maintained by USA Synchro at the request of the child, parent or guardian. In order to maintain membership for a person,
regardless of age, USA Synchro must maintain certain personal information regarding the member. The parent or guardian
understands that if s/he requests that such information be deleted from its online Membership Management System, USA
procedures for opting out under the membership section of www.usasynchro.org.
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.