AS&T WINTER SWIM PROGRAM

2017 -2018 REGISTRATION

FAMILY NAME ______

To complete your registration you will need to fill out and sign the following paperwork.

1. AS&T WINTER SWIM PROGRAM Registration form (1 per family)

2. Medical Release and Information form (1 per swimmer’s last name)

AS&T WINTER SWIM PROGRAM

2017 -2018 REGISTRATION

PARENT’S NAMES:
STREET ADDRESS:
CITY/ZIP: / HOME PH:
CELL PH. MOM: / CELL PH. DAD:
WORK PH. MOM: / WORK PH DAD:
E-MAIL MOM: / E-MAIL DAD:

AS&T Member Rates for Winter Swim 2016-2017

Cost per swimmer / SWIMMERS’ NAMES
(LAST, FIRST, MI) / SEX
M/F / BIRTH DATE
M/D/YR / TOTAL
1st - $170.00
2nd - $150.00
3rd - $130.00
4th - $130.00
5th - $130.00
Total Fees
Make check payable to AS&T

Non-Member Rates for Winter Swim 2016-2017

Cost per swimmer / SWIMMERS’ NAMES
(LAST, FIRST, MI) / SEX
M/F / BIRTH DATE
M/D/YR / TOTAL
1st - $370.00
2nd - $350.00
3rd - $330.00
4th - $330.00
5th - $330.00
Total Fees
Make check payable to AS&T

Refund Policy: Refunds will only be issued to families who provide notification in writing or e-mail to y September 18, 2017. No refunds will be issued after September 18, 2017 due to financial commitments to the JCCNV.

AS&T WINTER SWIM PROGRAM

2017-2018 MEDICAL RELEASE FORM

Please note: If your children have different last names, please complete a form for each last name.

PARENTS’ NAME(S): ______

HOME PHONE: ______

ADDRESS: ______

CITY/ZIP: ______

WORK PHONE-FATHER: ______MOTHER: ______

CELL PHONE - FATHER: ______MOTHER: ______

HEALTH INSURANCE CO.______GROUP #______

EXISTING MEDICAL CONDITIONS (SUCH AS ALLERGIES, MEDICATION ALLERGIES, OR CHILDREN OTHER SPECIAL PROBLEMS THAT SHOULD BE KNOWN)

FULL NAME / BIRTHDAY
1.
2.
3.
4.
5.

* If a swimmer has special requirements or is on regular medication, please list swimmer’s name and medication on the line below. Also, list any special instructions in case of illness or injury.

Please identify the Doctor or medical practice who is your child’s pediatrician or primary care physician.

FAMILY DOCTOR: ______PHONE: ______

ADDRESS: ______

If you are unable to contact the doctor, please accept this letter as your authority to use the Doctor on call in the Emergency Room for any necessary emergency medical treatment.

I, ______, the parent or legal guardian of the above listed child/children, give my permission and approval for participation of above named child/children, in any and all activities sponsored by the AS&T Winter Swim Program and I assume all risk and hazard incident to such participation, including transportation to and from such activities. I waive, release, indemnify and agree to hold harmless the AS&T Winter Swim Program, Coach, and Assistant Coaches, Club Officers, officials, participants and parents from any claim arising out of injury to my child/children while participation in any and all activities, including, but not limited to transportation to and from all practice swim sessions and competitive swim meets, sponsored by the AS&T Winter Swim Program.

I know of no impairment or deficiency, physical health or otherwise, that would limit or prohibit my child/children from participating in practice swim sessions and competing with other children. I agree to advise and make known to the AS&T Winter Swim Programand Coach any change in the physical health or any other condition that would limit or prohibit my child/children from participating in practice swim sessions and competitive swim meets.

PARENT’S SIGNATURE: ______

DATE: ______