NYAC SWIMMING & DIVING TEAM

2007 REGISTRATION FORM

Enjoy the fun and camaraderie of being on a team and learning new skills.

The Swimming and Diving teams are open children of members ranging between the ages of 5-17.

Swimming and Diving Team: Pre-season practices occur June 18th, 20th, and 22nd between 3:30pm-5pm. Regular season practices take place Monday through Friday from June 25th to August 8th between 8am-10am. The cost is $175 for the first child and $125 for each additional child.Pre-Team practices take place Monday through Friday from June 25th to July 27 between 12pm-1pm. The cost is $125 per child.

CHILD’S NAME: ______GRADE IN SEPTEMBER:

DATE OF BIRTH: ______Age: Sex:

ADDRESS:

MEMBER NAME: ______AUDIT #:

HOME PHONE: ______CELL #:

BUSINESS #: E-MAIL:______

CONTACT IN CASE OF EMERGENCY

1) NAME: CONTACT #

2) NAME: CONTACT #

3) NAME: CONTACT #

WHO IS AUTHORIZED TO PICK UP CHILD

RELATIONSHIP TO CHILD

SWIM TEAM (ages 7-17) PRE-TEAM (ages 5-8) DIVING

ALL CHILDREN MUST BE TRAVERS ISLAND POOL MEMBERS

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SIGNATUREDATE

2007 Tennis Academy Medical Form

This section is to be completed by parent(s) and physician at the time of examination. Please print or type the following information:

Please select which program your child will be enrolled in:

___ Jr. Tennis Academy___ Jr. Water polo ___ Pre- swim Team

___ Swim Team___ Diving Team___ Jr. Sailing

Name ______

Birth Date ___/ ___ /___Child’s Age ____

Parent/ Guardian ______

Address ______

City ______State ______Zip Code ______

Please check and comment on any conditions that NYAC should be aware of:

Allergies, Asthma ______Constipation ______

Sore Throats ______Defective hearing ______

Eczema, Other ______Defective vision ______

Frequent Colds ______Diabetes ______

Earaches ______other ______

Sinus Trouble ______

In case of a medical emergency and I cannot be reached after a reasonable effort has been made, I hereby give permission to the physician selected by the NYAC to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child named above.

______

SignatureDate

______

Emergency NameHome Work/Cell

______

Emergency NameHomeWork/Cell

(OVER)

THIS FORM IS TO BE COMPLETED BY YOUR CHILD’S PHYSICIAN

PLEASE GIVE THE IMMUNIZATION DATES FOR THE FOLLOWING:

DIPHTERIA______

MEASLES______

MUMPS______

POLIOMYELITIS______

RUBELLA______

TETANUS______

I certify that ______has been examined by me and is able to participate in programs held by NYAC.

______

PHYSICIAN’S SIGNATUREDATE

(Please Print)

CHILD’S NAME ______

DOCTOR’S NAME ______

DOCTOR’S ADDRESS ______

TELEPHONE ______

______

*Please note that no child will be admitted into any program without a medical release on file.