* 1. Name

* 2. Street, City & State (your address)

* 3. Age on swim date:

* 4. Cellphone

* 5. Additional Phone Number

* 6. Email Address

* 7. Medical information to declare

* 8. Open water experience

* 9. WAIVER & AGREEMENT: As a condition of being accepted in the June 4, 2016 Potomac River Swim, I agree to make timely payment of the total swim fee of $450 (entry fee $200 + pledges due on June 3 at pre-swim supper $250); 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.

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