2015/2016 Evergreen Swim Club
Contract and Registration Form
(All fields are required or forms/athlete registration will be returned)
*NOTE: Except for 1 week trial period, swimmers without current USA swimming registration fee, ESC contract, medical form, concussion form, and liability waiver will not be allowed in the pool.*
Account Registration Information
Father’s Name:______
LastFirst
Mother’s Name:______
LastFirst
Address:______
StreetApt #
______
CityState Zip
______
Note if physical address is different from above.
Home Phone:______
Main/Billing E-mail:______
Parents if swimmer is under 18
Additional E-mail:______
Father’s Work Phone:______Father’s Cell:______
Mother’s Work Phone:______Mother’s Cell:______
Who referred you to the team? ______
If my child needs to go home because of illness or accident and I cannot be reached, please call: ______Phone: ( ) ______
NAME:______
LastFirst Middle
Nickname:______Returning/New:______
Birthday:_____/_____/_____ Age:______Sex M / F Year in School:______
For USA Swimming Registration Form:
Disability: Race and Ethnicity: (Make up to 2 choices if appropriate)
____ A. Legally Blind or Visually Impaired ____ Q. African American_____ R. Asian
____ B. Deaf or Hard of Hearing ____ S. Caucasian_____ T. Hispanic or Latino
____ C. Physical Disability ____U. American Indian & Alaskan Native
____ D. Cognitive Disability _____ W. Native Hawaiian & Other Pacific Islander
_____ V. Some Other Race
U.S. Citizen? _____ Yes _____ No Are you a member of another FINA Federation? _____ Yes _____No
If yes, which Federation?______
Year last registered with a Swim Club ______. If you registered with a different WSA Swimming Club in 2014-15, enter that Club Code ______, LSC Code ______and date of last competition representing that Club____/____/___.
Medical & Emergency Information:Is your child taking any medication? (Insulin, sedative, tranquilizer, or anti-convulsive drug)?
Y/N If yes, please explain:______
______
Does your child have a significant health problem? (Heart disease, diabetes, allergies, asthma, or convulsive disorder)? Y/N If yes, please explain:______
______
List all medical and non-medical allergies of your child (penicillin, bee sting, strawberries):
______
If necessary, what specific action should be taken?______
______
IN AN EMERGENCY, if the Coach is unable to reach me, I hereby give my consent for treatment to be given by:
Doctor:______
Address:______
Street City Zip
Phone: ( ) ______
Dentist:______
Last First M.
Phone: ( ) ______
Insurance Carrier ______Group / I.D. #:______
Phone: ( )______
If the doctor/dentist named above cannot be reached, please take my child to the nearest emergency station, by ambulance, if required, for treatment. By my signature, I authorize any medical provider to give all necessary medical care. I authorize this information be accessed by coaches and pertinent board members as needed.
Signature of Parent/Guardian:______Date:______
Or Swimmer (if 18 years or older)
Evergreen Swim Club Age Group Contract ~ 2015-2016
~ Please read and initial each section to indicate you have read it. ~
CONTRACT: As part of the ESC program, all swimmers are committed to an annual contract and to pay monthly dues through July 2016. This contract may be cancelled, or a “time-off” taken, by providing a written 30 day notice to the Treasurer. Athletes may also opt to move to a “Conditioning” level during other sports activities or high school swim by notifying Treasurer. Initial
PAYMENT: On the first of each month, Evergreen Swim Club (ESC) will submit an on line statement. To access your account, go to: ESC Website: (click - $ My Invoice/Payment). Statements will contain fees for monthly dues, meet fees, and purchased swim gear. Payment is due by the 10th and considered delinquent if not received by the 15th of the month. The full monthly dues amount will be charged for each month regardless of the number of days swum (except new team members joining mid-month). Delinquent accounts will be assessed a $25 late payment fee for each late month. Accounts more than 30 days past due will be subject to a 1% interest charge per month in addition to the late penalty charges; in addition, the swimmer will not be allowed in the pool until payment and fees are current. Payments should be mailed or deposited through your bank’s electronic payment. Mail payments to: Evergreen Swim Club-Treasurer, P.O. Box 11823, Olympia, WA 98508-1823. Initial
MONTHLY DUES: Green: $75.00; Red:$100.00; Blue: $125.00; Conditioning: $85.00; Senior: $150.00.Dues will NOT be prorated except for extended absence due to medical reasons (doctor’s note required) or when initially joining the club. Families with more than two swimmers will receive a 10% discount on monthly dues for third swimmer in the youngest group; the fourth and subsequent swimmers will receive full scholarship. Initial
FEES: For new swimmers, a USA Swimming annual registration fee ($67) is required upon completion of your trial week. If a returning member, the annual registration fee will be billed on swimmer’s November monthly statement. All swimmers must be registered with USA Swimming in order to participate in Club practices or to attend meets as members. This is for your protection as it provides insurance for your swimmer and the Club. Insurance coverage may be viewed in detail on the website.
- For new swimmers who start after April 1, 2016, the USASeason 2 registration fee is $38.50.
- Season 2 swimmers, who wish to continue swimming after August 31st, must sign a new contract and pay the year-round USA registration fee prior to returning to practice in September of 2016.
- Swimmers are responsible for meet fees if they sign up for a meet—regardless of whether or not the swimmer attends the meet. Once the club pays the meet fees, we are unable to get a refund on those fees.
- Swimmers attending non-home meets will pay a $5 fee to help offset coach travel costs. Initial ______
WORK SESSIONS: I have read the Work Session page and understand my commitment of 20 volunteer hours per swimmer. Unfulfilled volunteer hours will be billed at a rate or $20 per hour. Initial
CODE OF CONDUCT: I have read and agree to follow the Evergreen Swim Club Code of Conduct. Initial
Available at:
FINANCIAL AID: Swimmers receiving free or reduced lunch through their local school may have their annual USA Swimming registration fee ($67) covered and receive up to 5 meet vouchers per year. To qualify,school districtdocumentation must be turned in to the ESC registrarwhen the 2015-2016swimmer contract is submitted.
PARKING: The Evergreen State College charges for parking. Two-hour parking passes are available for $1, and daily parking is available for $2. Quarterly and yearly passes are also available at the ESC police department and are highly recommended. Queries should be directed to the College, 866-6000; ask for public safety/parking. *These amounts are subject to change as per TESC yearly fees.
I have read the “Evergreen Swim Club Age Group Contract ~ 2015-2016”and Registration Information and understand my obligations to the ESC. I understand that fees will be adjusted when a swimmer changes groups. Meet fees and USA registration fees are separate obligations under this contract.
Parent/Guardian: ______Date: ______
Or Swimmer (if 18 years or older) Signature
ESC Work Session Obligations
ESC hosted meets are vital to our fundraising!
* All families must work a minimum of 20 hours per year per swimmer at ESC hosted meets and events. Although families may choose to work more, the obligation for meet work hours per family will not be more than 40 hours regardless of number of swimmer’s per family. Volunteer hours are not transferrable between families. The team’s Volunteer Coordinator will report time worked and update account information on the team web site. Initial
*For those who EXCEED 50 meet hours worked (regardless of the number of swimmers you have enrolled) your will receive a 25% reduction on swimmer’s dues for the month of June (meet fees not included). Families that have not fulfilled work session requirementswill be billed in June at a rate of $20 per un-worked hour. Should you leave the club prior to June, your session obligations will be prorated and you will be financially responsible for any unworked hours. Initial
*Work session opportunities will be listed on ESC’s website under each home meet event. Work session opportunities include food/drink donations and filling various positions during meet weekends.Initial
2015-2016Home Swim Meet dates: October 10-11, December 5-6, January 30-31, February 26-28
I have read and understand my Work Session Obligations for ESC’s 2015-2016 swim season.
______
Parent or Legal Guardian SignatureDate
------
ESC Discipline & Suspension Policies (from ESC 2015-16 Handbook)
Practice is the time for personal and team improvement. Actions that disrupt or interfere with the quality of the swimmer's practice and/or teammates’ practice will be dealt in the following matter:
- If a swimmer is disruptive in practices to the point that workout cannot continue, s/he will be removed from practice but will remain in the pool area spending the remainder of the time observing practice. The parent will be informed of the inappropriate behavior that day.
- A swimmer who repeatedly exhibits inappropriate behavior, physical or mental abuse to swimmers, coaches, or officials, or others may be suspended by a coach for a maximum of one week, with a mandatory meeting with the coach and parents that week. A hearing with the board is needed to suspend a swimmer for greater than one week or if a swimmer is to be suspended a second time during the same swimming season (September to August).
- Any swimmer who participates in any illegal activity during a PNS- or ESC-sanctioned event will be immediately suspended from the team and may possibly be removed permanently, depending on a hearing with the Board of Directors and the coaches' recommendation.
I have read and understand the ESC Discipline & Suspension Policies:
______
Athlete Name Printed Athlete Signature Date
______
Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date
EVERGREEN SWIM CLUB WAIVER AND RELEASE OF LIABILITY
I, ______, on behalf of myself and my child, have voluntarily requested to participate in the swim program offered by Evergreen Swim Club (ESC). I am aware that attending or participating in these activities involves risk of injury to person and property. I voluntarily accept and assume all risk from attending or participating in these activities.
In consideration of being permitted to participate in these activities, I agree, on behalf of myself and my child, our heirs, personal representatives, and assignees, not to make any claim against or sue Evergreen Swim Club (ESC); or their employees, officers, directors, agents, members or board members (collectively referred to as the “RELEASED PARTIES”); for any injury or damage to my child or myself arising from negligence, active or passive, or other acts, however caused, by the Released Parties.
In addition, I release and discharge the Released Parties for all actions, claims, or demands that I or my child, our heirs, personal representatives, and assignees have or may hereafter have for personal injuries to my child or myself, or property damage resulting because of the activities described above. This release includes injury or damage caused by negligence, active or passive, or other acts, however caused, by the Released Parties.
The undersigned parent hereby gives permission for any necessary medical care to be given to my child/children in case of accident or illness. I agree to assume full responsibility for the costs of any treatment provided.
By my signing this, I release Evergreen Swim Club and the ESC board of directors from any and all liabilities and waive all claims against them.
I HAVE CAREFULLY READ THIS AGREEMENT AND I UNDERSTAND THAT THIS IS A COMPLETE RELEASE OF LIABILITY, AS WELL AS A PROMISE NOT TO SUE OR MAKE A CLAIM.
Swimmer’s Name: ______Group: ______
Swimmer’s Name: ______Group: ______
Parent/Guardian: ______
Print Name
Parent/Guardian: ______Date: ______
Or Swimmer (if 18 years or older) Signature
Photo/Video Consent Form
I understand that promotional pictures and/or videos (individual and group) have been / will be taken during the upcoming swim season. I give permission for my son’s/daughter’s picture to be used for promotional materials (Face book, newsletter, web page, calendars, power point, etc.) in highlighting the events. NAMES WILL NOT BE USED.
Parent/Guardian: ______Date: ______
Or Swimmer (if 18 years or older) Signature
PACIFIC NORTHWEST SWIMMING
2015-2016Concussion Information Sheet
(THIS PAGE IS NOT TURNED IN WITH CONTRACT—I would like to combine this info and the next page onto 1 sheet that is signed.)
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.
Symptoms may include one or more of the following:
• Headaches • “Pressure in head”
• Nausea or vomiting • Neck pain
• Balance problems or dizziness • Blurred, double, or fuzzy vision
• Sensitivity to light or noise • Feeling sluggish or slowed down
• Feeling foggy or groggy • Drowsiness
• Change in sleep patterns • Amnesia
• “Don’t feel right” • Fatigue or low energy
• Sadness • Nervousness or anxiety
• Irritability • More emotional
• Confusion • Repeating the same question/comment
• Concentration or memory problems (forgetting game plays)
Signs observed by teammates, parents and coaches include:
Revised 7/26/15 Page 1
* Appears dazed
* Vacant facial expression
* Confused about assignment
* Forgets plays
* Is unsure of game, score, or opponent
* Moves clumsily or displays incoordination
* Answers questions slowly
* Slurred speech
* Shows behavior or personality changes
* Can’t recall events prior to hit
* Can’t recall events after hit
* Seizures or convulsions
* Any change in typical behavior orpersonality
*loss of consciousness
Revised 7/26/15 Page 1
~ Please sign and return the following Concussion Information Form. Keep this information sheet for your records. ~THE PROBLEM IS THAT THEY DO NOT KEEP THIS INFO FORM…
PACIFIC NORTHWEST SWIMMING 2015-2016
Concussion Information Signature Form:Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 9/1/2010
What can happen if my child keeps on playing with a concussion or returns too soon?
Athletes with the signs and symptoms of concussion must be removed from playimmediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under-report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and athletes is the key for athlete safety.
If you think your child has suffered a concussion
Any athlete even suspected of suffering a concussion must be removed from the meet or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The “Zackery Lystedt Law” in Washington requires the consistent and uniform implementation of long and well-established return to play concussion guidelines that have been recommended for several years:
“a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time”
and
“…may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.
You should also inform your child’s coach if you think that your child may have a concussion. Remember, it is better to miss one meet or practice than miss the whole season. And when in doubt, the athlete sits out. For current and up-to-date information on concussions you can go to:
This form must be signed and dated by BOTH athlete and parent or guardian BEFORE the athlete can participate in practice or competition.
______
Athlete Name Printed Athlete Signature Date
______
Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date
**Each swimmer MUST have a signed concussion form.**
Evergreen Swim Club ~ Travel Meets Swimmer Code of Conduct
PURPOSE
The purpose of this code is to promote the best possible individual, team, and program responsibility which supports the development of first class citizens at all times.This code governs participation in ESC events during travel away meets. The Evergreen Swim Club will seek out of town swimming competition for the following reasons:
A) Different individual competitions;
B) A higher quality of competition;
C) Experience in trial/finals competition;
D) Conditions conducive to exceptional performances.
PART I – GENERAL CODE OF CONDUCT RULES
1. No team meetings may be missed. Be punctual to all meetings and warm-up times.
2. Curfews at team travel events, as a member of Evergreen Swim Club or USA Swimming sponsored event and at all related activities, will be obeyed. Extension will only be granted by the Head Coach. Curfew is not enforced if participant is with parents.
3. At no times will male and female athletes be in the same room together with the door closed, unless supervised by designated Club official,( i.e. team chaperone, parent) . This applies to ESC members and members of any other team.