Membership Application

Clear Fork Swim Club Membership Application – 2024.

Please fill it out in it’s entirety.
New Since 2022 – Payment must be submitted directly after filling out.
TO PAY VIA CHECK PLEASE PRINT AND MAIL PAYMENT TO:
PO Box 3151 Lexington Oh 44904

The undersigned hereby applies for membership in the Clear Fork Swim Club and if accepted agrees to abide by the rules and regulations thereof and submits the following complete information. Season pricing can be found on the membership page.

Names and birth dates of children living in YOUR HOME:

The undersigned applicant for membership hereby acknowledges and agrees, for himself/herself and any and all of his/her family members who are eligible to use the Club and its facilities under the terms of the membership that may be granted herein, that normal use of the Club’s facilities may involve some level of risk and that, specifically, swimming and diving involve an element of inherent risk and that they specifically accept and assume all such risk of injury, damage, or loss associated with such use. Further, the undersigned applicant, for himself/herself and any and all of his/her family members, also hereby waive and hold harmless the Club, its officers, directors, agents, employees, volunteers and contractors of and from any and all liability arising from and as a result of their use of the Club and any of its facilities, whether arising from the negligence of or by the Club or any of its agents or otherwise.

EMERGENCY MEDICAL AUTHORIZATION
The purpose of this authorization is to enable parents and guardians to authorize the provisions of emergency treatment for children who become ill or injured while under the authority of the Clear Fork Swim Club when parents or guardians cannot be contacted.
* * *Part I or Part II must be completed* * *

PART I – TO GRANT CONSENT
In the event reasonable attempts to contact me at:

or other parent/guardian at:

have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by:

or

or in the event the designated preferred practitioner is not available by another licensed physician or dentist, and to transfer the child to:

The children under this consent are:

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery are obtained prior to the performance of such surgery. Facts concerning the children’s medical history including allergies, medications being taken and any physical impairments to which a physician should be alerted:

* * *Do not complete Part II if you completed Part I * * *
PART II – REFUSAL TO CONSENT
I do not give my consent for emergency medical treatment for my child(ren). In the event of illness or injury requiring medical treatment, I wish the Clear Fork Swimming Club authorities to take no action or do the following:

By submitting this application I agree to the Clear Fork Swim Club rules and regulations.