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Child's Name(1)

First MI Last
Birthdate: Teacher
Has your child participated in another swim club recently? Please state the club

Child's Name (2)

First MI Last
Birthdate: Teacher
Has your child participated in another swim club recently? Please state the club

Child's Name (3)

First MI Last
Birthdate: Teacher
Has your child participated in another swim club recently? Please state the club

Address
City , State Zip
Phone Work/cell Phone Other Phone
Parent(s)
Last Name
First Name
Spouse		  
Email(account id) Password:
Additional Email
Does your child have any medical conditions/disabilities that could limit his/her participation in the club? (yes/no)
If Yes, please explain
 

Please name any accomodations/medications needed for this condition
Doctor/Physician's Name
Medical Insurer/Provider
Emergency Contact Name: Relation:
  Address:
City,State,Zip:
  Home Phone: Work Phone:
Would you be interested in providing rides to swimming? (Yes or No)
Do you need a ride to swimming? (Yes or No)