East stroudsburg university of pennsylvania office of conference services

EAST STROUDSBURG UNIVERSITY OF PENNSYLVANIA

OFFICE OF CONFERENCE SERVICES

SPRING 2012

[phone]
<sup>A Member of

Pennsylvania’s State System

of Higher Educaton</sup>

AQUA TOTS

A SWIMMING/WATER PROGRAM FOR CHILDREN

(a non-credit course)

DESCRIPTION:

This program is designed for children to develop a comfort level in and around the water, as well as a readiness for learning to swim. In the Infant and toddler class a parent or other adult must accompany the child in the water. In the Levels I through VI classes - American Red Cross "Learn to Swim" Program - ages 6 years and older, the children will be water tested the first day of class to be placed at the appropriate level.

LOCATION: Koehler Pool - Located on Smith Street.
COST: $50.00 per child
DATES: Thursday, April 12, 2012 to Thursday, May 3, 2012 Mondays and Thursdays (7 total classes). Plus a required "new" parents orientation on Tuesday, April 10, 2012 at 7:00 p.m. in the Koehler Pool Area. The meeting is for parents only.
TIMES:

Section A / B (Toddler 6 months to 3 years old) 4:00-4:30 p.m.

Parent/Adult required in water
Please be aware, Sections A and B have been combined.

Section C (Preschool: 4 years to 5 years) 4:30-5:00 p.m.

Section D (Levels I through VI: 6 years & older) 5:00-5:30 p.m.

Section E (Levels I through VI: 6 years & older) 5:30-6:00 p.m.

Section F (Levels I through VI: 6 years & older) 6:00-6:30 p.m.

Section G (Levels I through VI: 6 years & older) 6:30-7:00 p.m.

PARKING:

All vehicles must park in the lot across the street from Koehler Fieldhouse. Map will be sent prior to first class.

INSTRUCTOR:

Dr. Caroline Kuchinski [phone]. For additional information regarding course content, contact the professor.

NOTE:

Spaces in these classes are limited. Only a properly completed registration form and full payment reserves a space. Safety does not permit over-enrollment. No telephone registrations will be accepted. A registration confirmation will be mailed to all officially registered participants.

Registration starts on January 3, 2012.
FEE: $50.00 Per Child. Please make check or money order payable to ESU.


TO REGISTER:

Complete the below registration form and mail or deliver it along with your check or money order to: Conference Services, 200 Prospect Street, East Stroudsburg University, East Stroudsburg, PA 18301. Registrations will be accepted on January 3, 2012 and continue until each respective class is filled. A separate registration form is required for each child.

************************************************************CLIP AND RETURN***************************************************************

REGISTRATION FORM FOR AQUA TOTS - SPRING 2012

REGISTRATION FOR AQUA TOTS (a non-credit course). Amount Enclosed___________ DATE_____________

REGISTER FOR SECTION A B C D E F G (CIRCLE CORRECT CLASS LETTER)

CHILD’S FIRST NAME________________________ M.I._____ LAST NAME_____________________________

CHILD’S BIRTHDATE ______________ CHILD’S AGE _______ MALE______ FEMALE_______

ADDRESS______________________________ CITY_____________________ STATE_____ ZIP________

EMAIL_____________________ PARENT’S TEL. NO. (CELL)________________ (HOME)_________________

HAS YOUR CHILD PARTICIPATED IN A SWIMMING CLASS BEFORE: YES__________ NO___________

IF YES, WHAT LEVEL COMPLETED ________________ WHERE:_______________________

NEW AQUA TOT PARTICIPANT: YES NO

PARENT/GUARDIAN’S NAME_________________________________________ RELATIONSHIP___________

I realize that risks of injuries are an inevitable and inherent consequence of participation in any sport activity; and that no amount of reasonable instruction and supervision, proper use of equipment or facilities will prevent all injuries. I realize, and understand that severe injuries are possible even from sport camp activities. I understand and appreciate that such injuries can range from the most insignificant to death, including but not limited to, serious neck and spinal injuries which may result in partial or total paralysis; brain damage; loss of sight, hearing, sense of smell or serious or permanent injuries to all bodily organs and functions. Serious injury can also occur to all or part of the musculoskeletal or nervous systems. All of these potential injuries can impact on the general health and well being of participants for the remainder of their natural lives.

In accepting this risk, I expressly and explicitly release, discharge and waive any and all responsibility and liability, and agree to indemnify and hold harmless, East Stroudsburg University of Pennsylvania, and the employees, officials or agents of any and all of the foregoing, pursuant to, pertaining to, related to, or arising from any injuries to my child as a result of his/her participation in this activity.

I verify that my child is covered by health insurance and that East Stroudsburg University of Pennsylvania and the State System of Higher Education, and the Commonwealth of Pennsylvania, and the employees, officials or agents of the foregoing are not responsible for any health care expenses as a result of my child's participation in this activity. If I do not have health insurance, I agree to be totally responsible for any and all health costs associated with any injury incurred by my child in participating in this activity.

In case of injury as a result of my child's participation in this activity, I hereby give advance permission to obtain medical service on behalf of my child, including but not limited to, paramedic treatment, transportation by emergency vehicle to a medical facility and treatment by emergency physicians. All extraordinary measures are to be taken in regard to treatment and I shall assume all financial responsibility as to any treatment. If emergency treatment is secured, I will indemnify and hold harmless East Stroudsburg University, the State System of Higher Education, and the Commonwealth of Pennsylvania, the employees, officials or agents of the foregoing from any and all actions in the decision to seek emergency treatment.

East Stroudsburg University and its representatives on occasion take photographs for the university’s use in print and electronic publications. This serves as public notice of the university’s intent to do so and as a release to the university of permission to use such images as it deems fit.

By my signature below, I hereby acknowledge that I understand and voluntarily accept, on behalf of my child, the hazards, risks, rights and responsibilities noted in the release.

Parent/Guardian Signature Date

For assistance or special accommodations, please call [phone].

Notice of Nondiscrimination - East Stroudsburg University of Pennsylvania does not discriminate on the basis of race, color, religion, national origin, sex, veteran status, disability or age in its programs and activities in accordance with state and federal laws. The following person has been designated to handle inquiries regarding this policy: Director of Diversity & Equal Opportunity, 200 Prospect Street, 115 Reibman Building, East Stroudsburg, PA 18301, 570-422-3656. aquatots041