Potomac River Swim - Swimmer Entry Question Title * 1. Name Question Title * 2. Your address, email & phone Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 3. Age on swim date: Question Title * 4. Medical information to declare Question Title * 5. Open water experience Question Title * 6. WAIVER & AGREEMENT: As a condition of being accepted in the June 1, 2019 Potomac River Swim, I agree to make timely payment of the total swim fee of $500 (entry fee $450 + $50 in pledges due on May 31 at the pre-swim supper); to attend the pre-swim supper/briefing; to adequately train for the swim; to abide by event rules and regulations including determinations that may result in my removal from the water; and to hold harmless by acknowledging and assuming the risks involved in an endurance activity of this nature and for myself and heirs waive all claims for damages or injury arising during the event against any individual, group, association, agency or government body involved with this activity's organization, conduct, and/or support. STATE YOUR NAME IF YOU AGREE. Question Title * 7. Emergency contact information (name & phone) Name Email Address Phone Number Done