Name:

Home Address:

Street address, community, state, zip code

Pool Pass #

Home Phone

Cell Phone

Date of Birth:

Age on June 1, 2010

Sex

Email address:

Mom’s Name:

Dad’s Name:

Mom’s Cell #:

Dad’s Cell #:

Mom’s Email:

Dad’s Email:

Emergency Contact

Emergency Contact #:

Medical Information :

Vacation plans

Change answers to NO if unable to do requested item

My name may be published on the team web site

Yes

My address may be published on the team web site

Yes

My phone number may be published on the team web site

Yes

LIABILITY WAIVER: In the event the swimmer named above is acutely injured or ill and requires emergency medical attention as determined by any member of the coaching staff, I give my permission for them to activate the Emergency Medical System on the swimmer's behalf. I agree to hold Valley Stream Village Inc. Valley Stream Swim Team its coaches, staff or designated officials harmless for actions taken to seek emergency care if deemed necessary. In addition, I understand that participation in swimming activities has an inherent risk and will not hold coaches or staff responsible for injuries that occur to the swimmer as a result of participation. I also agree to notify the appropriate personnel if there is any change in the information listed above. This waiver is in consideration of the privilege to participate on the Valley Stream Swim Team.

Fee Paid

Shirt Received

Swimmer Signature

Cap Received

Ordered Equipment

Equipment Received

Parent Signature