FCBDD ➤ Monday Night Swim Monday Night Swim Staff Recreation/Family Swim Program September 14, 2026 – May 24, 2027 Name of Individual Serviced by FCBDD:Parent/Guardians:Children Names:PhoneBuilding or Department of Staff Member:Children Names:PhoneGroup Home/Residential/Other:Staff Member Name:Participants Names:Emergency ContactPhone Country Phone Number Special Precautions (Behaviors, Seizures, Medications):Please Acknowledge(Required) I acknowledge that I have read the rules linked above. I understand that my participating in the Staff Recreation/Family Swim Program may involve certain risks and I release the Franklin County Board of Developmental Disabilities and any staff member or volunteers connected wit the administration of the program, including lifeguards, and all others, from liability for any injury to me and my family and any damage to my property that may result from my or my families participation. SignatureDate Δ