KINGSBROOKE SEA LIONS SWIM TEAM
2011 WINTER SWIM REGISTRATION FORM
Please fill out the fields below to register your swimmers.   Fields marked with an asterisk (*) are required fields.
 
*Parent/Guardian Name(s)

*Mailing Address

*City, State, Zip Code

*Home Phone

- -

Work Phone

- -

Cell Phone

- -

*Email Address(es)

For multiple email addresses, please separate with a semicolon
Emergency Contact Name
(other than parent/guardian)

Emergency Contact Phone

- -

Physician Name

Physician Phone

- -

*Insurance Carrier & Member Number

*Any Medical Conditions the coaches should know about?

Please register your swimmer(s)in the age group he/she will be swimming during the 2011 summer season.
 
*First Name
*Last Name
*Program
*Sex 		*Date Of Birth (mm/dd/yyyy) *Age (as of
6/1/11)
*T-Shirt Size**
1.
2.
3.
4.
5.
* Space is very limited. Registration will be on a first come, first served basis.
T-shirt sizes tend to run small. If you are unsure, please choose a larger size.
Registration Fees: $160 first swimmer, $150 second swimmer, $140 third swimmer, $0 fourth (and any additional) swimmers per household.     (includes team t-shirt for each participant)
Payment Method *        Note: credit card payments will be assessed a $5 processing fee per swimmer

Please make all checks payable to 'Kingsbrooke Swim Team'. Do not send cash.

Upon completion, please print a copy of this information, sign, date, and mail/deliver with payment to:
Kingsbrooke Swim Team, 13480 Falcon View Ct, Bristow, VA 20136
Participation Agreement
Please read carefully.
I acknowledge fees are non-refundable after February 6, 2011. Credit card processing fees are not refundable. I agree to abide by all facility rules and regulations. I give my permission for my child/ren's picture to be used on the team website and/or in local team promotional publications or advertisements. I represent that my child has no life-threatening conditions. I know that swimming and water activities involve a degree of risk; by participating in the program, I accept all risks associated with the use of the facility and participation in the program. If the participant is a minor, I accept all risks on his or her behalf as parent or legal guardian. I hereby release the Kingsbrooke Sea Lions Swim Team, its Board members, coaches, volunteers, the Kingsbrooke Homeowners Association, City of Manassas Park and its employees, and independent contractors for any and all damages for personal injury arising in any way from use of the facility or participation in the program. I hereby give my permission for the swimmers listed above to be administered any and all medical attention necessary in the event of an accident, injury, sickness, etc. under the direction of his or her coaches until such time as I can be contacted. I agree to look solely to my insurance carrier to pay any damages I suffer. If the participant is a minor, I execute this release for the duration of the summer swim season on his or her behalf as his or her parent or legal guardian.

Signature
Date
       Parent/Legal Guardian
 
After you submit your information, you will receive an copy of the completed registration form via email.