| ENCHANTED VALLEY SWIM TEAM 2010 | |||||||||
| REGISTRATION / MEDICAL RELEASE | |||||||||
| SWIMMER NAME | AGE: AS OF MAY 31, 2010 | BIRTHDAY | |||||||
| PARENT NAME(S) | * E-MAIL IS IMPORTANT FOR TEAM COMMUNICATION | ||||||||
| SUBDIVISION | * E-MAIL ADDRESS | ||||||||
| ADDRESS | CITY | ZIP | |||||||
| HOME PHONE | DAYTIME EMERGENCY # | ||||||||
| CLOSE FRIEND OR NEIGHBOR | PHONE # | ||||||||
| PRIMARY INSURANCE CARRIER | |||||||||
| POLICY OR MEMBER NUMBER | GROUP # | ||||||||
| DOCTOR | PHONE # | ||||||||
| HOSPITAL | PHONE # | ||||||||
| CHECK IF YOUR CHILD HAS ANY OF THE FOLLOWING CONDITIONS: | |||||||||
| ASTHMA | DIABETES | HEART CONDITION | SEIZURE DISORDERS | ||||||
| ALLERGIES (LIST) | OTHER (LIST) | ||||||||
| In case of accident or serious illness, I request the Enchanted Valley Swim Team coach to contact me. If I am unable to be | |||||||||
| reached I authorize the team coach to call the physician indicated above and follow his instructions. If the physician cannot | |||||||||
| be contacted, the swim team coach is authorized to take immediate steps for emergency treatment. | |||||||||
| INTERNET RELEASE | |||||||||
| By registering my child for the Enchanted Valley Swim Team, I agree to allow my child's name and times to be posted on the team | |||||||||
| website at www.evswimming.com and the league website at www.nwal.org. I understand that my child's and other family members' | |||||||||
| pictures could be posted on the website, as well. | |||||||||
| SIGNATURE: | Date: | ||||||||
| REFUND POLICY: There will be no refund given after the second week of practice. Any parent requesting a refund before | |||||||||
| the second week of practice will be given a 50% refund. | |||||||||
| * E-Mail addresses will be kept private and will only be used to communicate Enchanted Valley Swim Team information. | |||||||||