Parent/Guardian's Name(s):
Mailing Address: Street
City, State, Zip
Phone Number / Alt. Contact Number:
Email(please print clearly)
Emergency Contact (name and contact Number):
Swimmer's Name
(w/ middle initial)
Date Of Birth: / Gender / M/F
Swimmer's Name
(w/ middle initial)
Date Of Birth: / Gender / M/F

SPRINGSESSION:March 15-June 10, 2016

Swim Practice: Monday through Friday from 5:15pm-6:45pm

Dryland Option: Tuesday/Thursday/Friday 4:45pm-5:15pm

REQUIREMENTS: All swimmers must be registered with USA Swimming and bring a snorkel and fins to practice.

If you having any questions regarding the Advanced Racing Group please contact Mean Mike at .

Swim ONLY Pricing: / Member $565 Non-Member $705.40 /
Dryland OPTION: / Member $180 Non-Member $226.80
TPC Member / Member #
Non-Member / Non-Members: Please read and complete the form on the back. If you are paying by check, please complete the form and attach the check to the form. Thanks!!

I understand that no refunds will be given for NBA Swim Team after 4:00 p.m. on March 18, 2016.

I further understand that there will be no credits given for NBA Swim Team. Rates will not be prorated for those swimmers who opt to attend less than the full workout schedule.

Parent/Guardian Signature

Non-MemberCredit Card Authorization Form

If your credit card becomes invalid or expire, please contact Member Services to update your information. Any amounts unpaid at the end of the billing month will be subject to a $25.00 late fee.

Please Print Legibly. All fields must be completed

Mandatory Field
Name
Mandatory Field
Mailing Address
City / State / Zip
Mandatory Field
Email Address
Home Phone
Alternate Phone

I, ______, as a Non-Member of the Tiburon Peninsula Club, hereby authorize Tiburon Peninsula Club to use the credit card account shown below for payment of services rendered by the Tiburon Peninsula Club or representatives of Tiburon Peninsula Club. I acknowledge that I am the representative for all persons listed in the non-member account on this form.

For payment by credit card: Every month you will receive a statement summary of activities. Tiburon Peninsula Club will charge the Credit Card provided. Please be sure to update Member Services with any changes or updates to the billing information provided. You will be charged $35.00 for all declined transactions. Should your Credit Card expire or decline Tiburon Peninsula Club charges, you will be subject to a declined transaction fee of $35.00 and activity participation will be subject to suspension. If payment is not received before the end month the statement summary is received you will be subject to a late payment charge no less than $25.00.

Form of Payment:

Visa/Master Card / American Express / Check #______
Credit Card Number / Expiration Date / Security Code
Print Card Holder Name / Card Holder’s Signature