Name: ___________________________________________________

                  Age: ___________                 Sex: _________

Address: _________________________________________________

City: _________________________________ State: ____ Zip Code: ____________

Email _________________________________________________________________

Fee Enclosed: _______________    Club Affiliation: _____________________________

Emergency Contact: ____________________________ Phone ____________________

(Make check payable to: OCCC )

As a participant in the program, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume full risk of any injuries, damages or loss which I may sustain as a result of participating in any and all activities connected with or associated with such program.

I agree to waive and relinquish all claims I may have as a result of participating in the event against the City and its officers, agents, servants and employees, the Ocean City C-Cerpants, its coaches and Board of Directors.

I do hereby fully release and discharge the City, and Aquatic & Fitness Center officers, agents, servants and employees, the Ocean City C-Cerpants, its coaches and Board of Directors from any and all claims from injuries, damage or losses sustained by me arising out of, connected with, or in any way associated with the activities of the event.

I further agree to indemnify and hold harmless and defend the City of Ocean City and the Aquatic & Fitness Center and its officers, agents, servants and employees, the Ocean City C-Cerpants, its coaches and Board of Directors from any and all claims from injuries, damage or losses sustained by me arising out of, connected with, or in any way associated with the activities of the event.

I have read and fully understand the above Event Details, Waiver and Release of all Claims and Permission to Secure Treatment.

Name: (please print): ____________________________________________

Signature: ____________________________________________________

Date: ______________________