Valley Isle Aquatics Registration Form

Session: Upcountry New Year 2012 Saturdays

Location: Pukalani Pool (Saturdays)
Session Dates: 1/14, 1/21, 1/28, 2/4, 2/11, 2/18, 2/25, 3/3
Number of Lessons: 8
Session Cost: $129.05

All payments and class registrations MUST go through our website;
if not, they are NOT valid classes; and Valley Isle Aquatics may NOT be held liable.

Note: Items marked * are required

Facility

Facility* Kihei UpCountry Central

Personal Details

Student's First Name*
Student's Last Name*
Both Parent's/Guardian's First Name*
Both Parent's/Guardian's Last Name*
Email Address
*

*Please do provide your email as this is our only way of sending you a confirmation email.

Student's Age*
Student's Birthdate*
Student's School & Dismissal Time*

Gender

Gender* Female Male

Address Details

House Number & Street*
Town/City*
State*
Zipcode*
Home Phone*
Cell Phone*
Work Phone*

Payment Details
Please complete the following items according to your account information which you are using to make your payment. This will assist us in matching your payment with your registration form. You do NOT need a PayPal account!

PayPal or Payment Account Name*

*Important if using a different account name than the registration name.

Email Address (PayPal or Payment)*
Company Name (if paying via company account)*

Please check the box for the time and level class you are registering.
We are only offering classes, times, and levels that are listed.
Please do NOT submit a blank registration form; this only delays the process and does NOT guarantee your child a space in the class.
Your child will NOT be enrolled in a class until your payment and completed registration form is received AND you receive a confirmation email from us.

Levels & Times	10:15	11:15	12:15	1:15	2:15	3:15
Pre-School Red
Pre-School Red-Orange
Pre-School Orange

Red
Red-Orange
Orange
Orange-Yellow
Yellow
Yellow-Green
Green
Middle School
Adult
Parent-Infant	10:00 NA
Parent-Toddler	10:00 NA
WSI Class

I give my consent/permission to Valley Isle Aquatics to use my child's picture/image. Full Policy
I do NOT give my consent/permission to Valley Isle Aquatics to use my child's picture/image.
Submitting this registration form does NOT guarantee you a spot in the class.
Please be aware that classes with fewer then four (4) students will be CANCELLED!
There are NO REFUNDS.
Read the full Refund and Cancellation Policy.
By submitting this registration form, you agree with the terms listed below.

All payments and class registrations MUST go through our website;
if not, they are NOT valid classes; and Valley Isle Aquatics may NOT be held liable.

Valley Isle Aquatics PO Box 367 Haiku, HI 96708 (808) 572-4665
valleyisleaquatics@valleyisleaqutics.com
(C)2010-2012 Designed by Maui Tech Girl

County of Maui
Department of Parks & Recreation
Community Classes

The County of Maui does not discriminate on the basis of disability in admission, access to,
or operation of its programs, service, or activities.
The County of Maui does not discriminate on the basis of disability in its hiring or employment practices.
We are committed to making all of its programs and leisure services accessible to everyone including persons with disabilities.
Do you have need for reasonable modifications? _____ Yes _____ No
Question, concerns, complaints, or requests for additional information regarding compliance
with the Americans with Disabilities Act may be forwarded to:
Community Courses Office
Floyd Miyazono
700 Haliÿa Nakoa Street #2
Wailiku, HI 96793
(808) 270-7383 voice
floyd.miyazono@mauicounty.gov

Release and Covenant Not to Sue
In consideration of the permission granted to me by the Department of Parks and Recreation of the County of Maui,
State of Hawai'i, to attend or participate in the above described a"Calibri"ctivity
>I, the undersigned, hereby release the above named Instructor and the County of Maui, its officers and employees,
from all actions, causes of action, damages, claims, or demands which
I, my agents, successors, assigns, heirs, executors or administrators, may have against said Instructor or the County of Maui,
its officers and employees, for the property damage and personal injury, including but not limited to
claims for wrongful death, known or unknown, which may be
sustained or incurred by my attendance or participation in the above described activity.
I also covenant, on behalf of myself and my agents, successors, assigns, heirs, executors or administrators,
to never institute any legal action against said Instructor or the County of Maui,
its officers and employees, or in any way aid in the prosecution of
any claim or action for damages, costs, loss of services, expense or compensation,
arising our of my attendance or participation in the above-described activity.
I, the undersigned,
have read this release and Covenant Not to Sue
and understand all its terms. I execute it voluntarily and with full knowledge of its significance.