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* 1. Participant Name

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* 2. Company Name

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* 3. Participant Address

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* 4. Participant Age

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* 5. Participant Date of Birth

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* 6. Emergency Contact Name

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* 7. Emergency Contact Phone Number

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* 8. Emergency Contact Relationship

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* 9. Medical Condition/Medication

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* 10. Payment Method

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* 11. Course Name

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* 12. Class Date

Date

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* 13. Class Location

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* 14.
REFUND and CLASS TRANSFER POLICY REFUND POLICY


There are no refunds once the course fee has been received. Includes: participants who do not successfully complete the course or course prerequisites, do not attend all scheduled class dates and times, do not pass course skills with proficiency (according to American Red Cross requirements) or do not pass the written exam with a score of at least 80 percent.


CLASS TRANSFER | Class Transfer Fee is $25.00

The class transfer fee is $25.00 and must be received to transfer class dates. Participants must submit the Class Transfer Form online at least 72 hours prior to the original class date. Participants may transfer a total of one time and training must be completed within 90 days of the original class date. Please choose a class date and location you will be able to attend. If no courses are available, a new one will be scheduled, or the original class fee can be credited towards other Heart Strong Wellness LLC Services and/or Products within 90 days of the original class.   


CANCELLED CLASS

Heart Strong Wellness LLC reserves the right to cancel any class. If a class is cancelled, registered participants will be given the option to transfer to another class date or receive a full refund.

CONTACT AUTHORIZATION

Heart Strong Wellness LLC reserves the right to use contact information (cell, text, email) to communicate any schedule updates and announcements. 

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* 15.
AMERICAN RED CROSS COURSE PREREQUISITES AND COMPLETION REQUIREMENT

American Red Cross requires participants to successfully complete the following prerequisites, to receive certification. Refunds will not be issued to participants who do not successfully complete all course prerequisites and course completion requirements, according to the American Red Cross standards. Please make sure you can complete the following course prerequisites and course completion requirements before you attend class. Thank You!
   
AMERICAN RED CROSS LIFEGUARD & LIFEGUARD REVIEW COURSES

1. Participants must be at least 15 years old on the last class date

2. Participants must complete the American Red Cross 8 Hour Online Course prior to the first class date (new certification only)

3. Participants must swim 300 yards continuously, without stopping - using the front crawl or breaststroke only

4. Participants must tread water for 2 minutes, using legs only - participants may not use their arms and their face must remain above the water at all times

5. Timed Drill (1 minute, 40 sec): Participants must swim 20 yards, dive down and retrieve a 10 pound weight from 7 feet deep, then swim back another 20 yards with the 10 pound weight in their hands using their legs only, Participants must keep two hands on the weight and their face at or near the surface at all times. Once the participants reach the pool wall they must place the weight on the pool deck and climb out of the pool with no assistance. According to American Red Cross requirements, participants may not wear googles for this drill.

6. Lifeguard Re-certification participants must hold the following current American Red Cross certifications: Lifeguarding, First Aid, CPR/AED for the Professional Rescuer (recertification only)

7. American Red Cross also requires the following for successful course completion: participants must attend all scheduled dates and times, demonstrate proficient skills and pass a written exam with a score of at least 80 percent.

 
AMERICAN RED CROSS FIRST AID/CPR/AED COURSES

Participants must be at least 13 years old

1. Participants must complete the American Red Cross 2.5 Hour Online Course, if applicable, prior to the first class date for Blended Class offerings.  Not all classes have Blended Course options.

2. American Red Cross requires the following for successful course completion: participants must attend all scheduled dates and times and demonstrate proficient skills.


AMERICAN RED CROSS BASIC WATER RESCUE & WATER SAFETY TODAY COURSES

3. Participants must be at least 13 years old

4. American Red Cross also requires the following for successful course completion: participants must attend all scheduled dates and times, demonstrate proficient skills and pass a written exam with a score of at least 80 percent. There is no written exam or in-water session for Water Safety Today.

 5. The American Red Cross requires participants to successfully complete the above prerequisites, in order to receive certification. Refunds will not be issued to participants who do not successfully complete any and all the course prerequisites and course completion requirements, according to the American Red Cross Standards.

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* 16. Participant Signature

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* 17. Parent/Guardian Signature (if participant is under the age of 18 years old)

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* 18.
Heart Strong Wellness LLC Course Participant Waiver/Release Form (“Agreement”)

IN CONSIDERATION of being permitted to participate in any way in the activity: LIFEGUARDING, WATER SAFETY TODAY, WATER SAFETY FOR SWIM COACHES, FIRST AID, CPR AND/OR AED COURSES ("Activity") I, for myself, my personal representatives, assigns, heirs, and next of kin:

1. ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity (Swimming and other water related activities), that I voluntarily wish to participate and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.

2. FULLY UNDERSTAND that: (a) CLASS PARTICIPATION, ESPECIALLY ACTIVITIES INVOLVING SKILL PRACTICE AND TESTING (ESPECIALLY IN-WATER PRACTICE AND TESTING), HAVE DAMAGES, RISKS OF INJURY INCLUDING SERIOUS BODILY INJURY OR DEATH (Risks); (b) TRAVELING TO AND FROM CLASS at the start, end, or break of class, OR TRAVELING TO SEPARATE TRAINING SITES, if two or more training sites are utilized, may involve driving, ride sharing, or otherwise traversing public streets, THEREBY INCURRING ADDITIONAL RISK OF INJURY INCLUDING SERIOUS BODILY INJURY OR DEATH (Risks); (c) these Risks may be caused by my own actions or in actions, the actions or in actions of others participating in the Activity, the condition in which the Activity takes place or THE NEGLIGENCE OF THE "RELEASES" NAMED BELOW; (d) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the Activity.

3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE Blackhawk High School, Riverside High School, Hopewell Jr. High School, Clearview Swim & Health Club, Heart Strong Wellness LLC, Mary Ann Miller, and their instructors/coaches/leaders conducting the Activity as well as their agents, employees, third party contact instructors, guest speakers, or assistants; the certifying agency if course certificates are being issued; other course participants; and, if applicable, the owners and lessors of premises on which the Activity takes place (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS, NEGLIGENT SECURITY, AND RECREATIONAL OPERATIONS AND ACTIVITIES; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releases, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim.

4. CONSENT, AUTHORIZATION, AND RELEASE OF PICTURES AND VOICE: the undersigned UNDERSTANDS AND ACKNOWLEDGES that during my participation with Heart Strong Wellness LLC, pictures, including video and still pictures may be taken of the undersigned and with sound of undersigns voice and may subsequently be used for promotion, marketing and social media purposes. I AUTHORIZE the use of my name and pictures including any accompanying voice to be exhibited with or without advertising pictures, television, video, social or similar media and HEREBY RELEASE HEART STRONG WELLNESS LLC, MARY ANN MILLER AND THEIR INSTRUCTORS, ASSISTANTS, EMPLOYEES AND AGENTS FROM ANY AND ALL CLAIMS FOR THE TAKING AND USE OF THE SAME.

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* 19. Participant Signature 

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* 20. Date Signed

Date

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* 21.
MINOR’S RELEASE – ONLY IF PARTICIPANT IS UNDER THE AGE OF 18 YEARS
AND I, THE MINOR'S PARENT AND\OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF AFOREMENTIONED ACTIVITY AND THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE "RELEASEES" FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS, AND FURTHER AGREE THAT, DESPITE THIS RELEASE, IF I, THE MINOR, OR ANYONE ON THE MINOR'S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.

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* 22. If Applicable, Print Parent/Guardian Name

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* 23. If Applicable, Parent/Guardian Phone Number

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* 24. If Applicable, Date Completed

Date
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