Year-Round Competitive Swimming & Water Polo

Year-round Competitive Swimming & Water Polo

REGISTRATION & MEDICAL INFORMATION

I. NAME: ______Date of Birth: ___/____/___

FIRST MILAST

PARENTS’ NAMES: ______

PHONE #: ______EMERGENCY # :______

Mailing Address: ______

II. WEB CONNECTIONS

Parents’ email: ______

Athlete cell #(HS): ______& Email: ______

Permission to post athlete’s photo on DCA website & Facebook page: Y N

III. MEDICAL INFORMATION:

1. Is your child allergic to any food or medications? ___Y ___N

If yes, please list: ______

2. Is your child taking any medication on a continuous basis? ___Y ___N

If yes, please list: ______

3. Has your child been treated for (circle all that apply)?

AsthmaDiabetesSeizures or Epilepsy

Heart DiseaseKidney or Liver DiseaseLung Disease

4. Has your child had any of the following in the last 2 years (circle)?

Head InjuryFracture

5. Does your child wear contact lenses or a dental appliance? ___Y ___N

Please list any medical condition we should be aware of that could affect your child’s practice or performance… ______

“These questions have been answered truthfully to the best of my knowledge. My son/daughter does not have any medical conditions that would adversely affect his/her personal safety while in or around the water. To the best of my knowledge, my child is healthy enough to participate in a rigorous, aerobic-based, competitive SWIMMING & WATERPOLO, a higher risk, contact sport.”

Signature: ______Date: ___/___/____

IV. USA SWIMMING REGISTRATION $65. Returning members must pay by 11/1/2016. NEW MEMBERS ONLY: pay within first week on the team & include PROOF OF AGE. USA Water Polo online at: .

V. PARENT AUTHORIZATION & MEDICAL TREATMENT FORM

This is to certify that I, as parent or legal guardian approve of and give my permission for my son/daughter ______to participate in swimming & water polo & dry land activities with Duke City Aquatics and certify that he/she is in good health and able to compete in the above-mentioned sports.

In consideration of my son or daughter's participation in the activities offered by Duke City Aquatics, I understand and voluntarily accept this risk and agree that Duke City Aquatics, its officers, directors, employees, volunteers, agents, independent contractors, any properties and/or facilities will not be liable for any injury, including, without limitation, personal, bodily, or mental injury, economic loss or any damage to me, my spouse, guests, unborn child, relatives or anyone using the facilities whether related to exercise or not.

I also hereby give permission for my son/daughter to receive medical treatment in any emergency situation when I cannot be reached.

FATHER’S NAME: HOME PHONE #: WORK PHONE #:

MOTHER’S NAME: HOME PHONE #: WORK PHONE #:

EMERGENCY CONTACT (IF PARENTS CANNOT BE REACHED):

NAME: PHONE #:

FAMILY DOCTOR: ______PHONE #: ______

DENTIST: ______PHONE #: ______

Dates of last Tetanus inoculation: ___/___/____

Medical Insurance Carrier: ______

Policy or Account #: ______

If your child has any special medical problems or allergies that we should be aware of, please list them here: ______

______.

If, in an emergency, we cannot be reached and our family doctor is not available, this form serves as consent for our/my child to be cared for by the closest available medical personnel and facility.

Signature of Parent or Guardian: ______

Printed Name: ______

Date: ___/___/____