Permission Slip & Waiver/Release
Child’s Name: ____________________________________________
Parent/Guardian Name: ____________________________________
Address: ____________________________________
____________________________________
Emergency Phone #: ____________________________________
I hereby grant permission for my child/s
elf to participate in swimming and/or outdoor activities at the home of Micky & Jane Thornton, located at 4962 Hwy 59 West, Covington, TN 38019. I understand that these activities involve a certain degree of risk, including injury to person, of which I am fully knowledgeable and which I hereby voluntarily assume for my child/self. I further release and hold harmless Micky, Jane Thornton & family from any and all liability in connection with the use of their pool, including any injury that may occur while at there home. I further grant permission for my child/self to swim and certify that my child/self can swim. In the event that my child/self can not swim I will provide them/self with all necessary flotation devices for use while in or near the water.
___________________________________ _______________
Parent/ Guardian Signature Date
