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Get MCA Silver Spring Piranha's Swim-A-Thon Pledge Sheet

YMCA Silver Spring Piranha s Swim-A-Thon Pledge Sheet Monday Tuesday Wednesday Nov 10 11 12 2014 During practice times YOUR NAME STREET ADDRESS CITY STATE HOME PHONE WORK PHONE ZIP E-MAIL ADDRESS EMERGENCY CONTACT DONOR S PHONE ADDRESS PHONE EMAIL PLEDGE/LAP TOTAL PAID If needed please include additional donor s on the back of this form. Please make checks payable to the YMCA SILVER SPRING SWIM-A-THON. I understand that the YMCA of Metropolitan Washington assumes no responsibility for injuries or illnesses which I may sustain as a result of my physical condition or resulting from my participation in the 2014 SWIM-A-THON. I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illnesses which may result from participation. I hereby release and discharge the YMCA of Metropolitan Washington its agents servants and employees from any and all claims for injury illness death loss or damage which I may suffer as a result of my participation. I understand that the YMCA of Metropolitan Washington is not responsible for personal property lost or stolen while members and/or program participants are using YMCA facilities on YMCA premises. I give my permission to the YMCA of Metropolitan Washington to use without obligation photographs film footage or tape recordings which may include my image or voice for purpose of promoting or interpreting YMCA programs. I acknowledge the WAIVER set forth above. Signature of Participant/Parent/GuardianDate parent/guardian if under age 18. I give my permission to the YMCA of Metropolitan Washington to use without obligation photographs film footage or tape recordings which may include my image or voice for purpose of promoting or interpreting YMCA programs. I acknowledge the WAIVER set forth above. Signature of Participant/Parent/GuardianDate parent/guardian if under age 18. .

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