Circle One: Former Swim Team Member New Military Family New Non-Military Family
Parent / Guardian
Information
Father’s
Name: _____________________________________________Work Number: (_________)
_________-____________
Cell Number: (_________)
_________-____________Email Address:
________________________________________________
*will be used for all team
communication
Mother’s
Name: _____________________________________________Work Number: (_________)
_________-____________
Cell Number: (_________)
_________-____________Email Address:
________________________________________________
*will be used for all team
communication
Mailing Address:
___________________________________________________________________________________________
Street Address City State Zip
Home
Phone Number: (_________) _________-____________
Emergency
Contact: _________________________________________Phone Number: (_________)
_________-____________
Vehicle #1 Info:
______________________________________________________________________________________________
Make/Model Color License
Plate
Vehicle #2 Info:
______________________________________________________________________________________________
Make/Model Color License
Plate
Swimmer’s Information
|
Last Name |
First
Name
|
MI |
Age |
DOB |
Program |
Annual
|
Winter/Spring |
Winter Only |
|
EXAMPLE: Smith |
Jonathan (Jon) |
E |
16 |
|
Senior 1 |
X |
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I
certify that the foregoing information is true and correct to the best of my
knowledge, and that the above swimmer(s) are in good health, with no physical
limitations. I will notify the head coach if there is any change in their
condition. I agree that in registering the above swimmer(s) I am responsible
for paying the total amount due for the program(s) that the swimmer(s) has/have
been registered in. I further understand that I am responsible for full program
payment if the swimmer(s) drop(s) out of the program anytime after an initial
two week trial period. In signing this form, I/we release Jersey Storm Swimming,
the Swim Team Parents Association (STPA), its Board of Directors, and coaching
staff from any/all liability incurred as a member of the team or as a
participant in team functions or activities.
Parent/Guardian Signature:
____________________________________________________Date:______/______/____________
Participant Signature (if over 18):
________________________________________________Date:______/______/____________