Mt. Pleasant Aqua Club

Registration

Winter 2008

Accepting all swimmers at all levels

Only 1 child per form

NAME ____________________________________________________________ M/F

DOB _______________________________ AGE AS OF MARCH 31, 2009 ______________

ADDRESS ___________________________________________________________________

___________________________________________________________________

PARENT/LEGAL GUARDIAN __________________________________________________

PHONE ___________________________________________

CELL PHONE _____________________________________

WORK PHONE ____________________________________

EMERGENCY CONTACT ___________________________ PHONE ___________________

Please list an medical conditions/allergies that your child may have and list any medications that are applicable:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

The Mt. Pleasant Aqua Club DOES NOT provide insurance for any participant in the aqua club program. The undersigned parent or guardian represents that the swimmer is in good health and able to participate in swimming practices and competitive swimming. He/she hereby releases the Mt. Pleasant Aqua Club and its officers from any and all responsibility for an injury to the above swimmer while he/she is participating in this activity.

I/We grant the Mt. Pleasant Aqua Club permission to use picture(s) of the above listed swimmer taken for the express use of the Mt. Pleasant Aqua Club on its website for promotion of the club.

SIGNATURE OF PARENT OR GUARDIAN:_______________________________________