Mermaids Registration




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Part 1: REGISTRATION FORM

Swimmer’s Name:

Session Attending:

Date of Birth:

Age:

Address:

City:

Zip:

Resident of the City of Scottsdale: YesNo

Mother’s Name:

Phone:

Cell:

Work:

Father’s Name:

Phone:

Cell:

Work:

Contact number in the event of a late cancellation:

Parent email:

I hereby certify that my swimmer is physically able to participate in synchronized swimming and has no physical condition that should prevent or preclude her participation, or any condition that would be aggravated by her swimming.

Parent Signature:

Date:

Part 2: MEDICAL TREATMENT RELEASE FORM

To Whom It May Concern:

In the event of an emergency or non-emergency situation requiring medical treatment, I/We hereby grant permission for any and all medical attention to be administered to my child ; date of birth in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to the administration of first aid, the use of an ambulance, and the medical or surgical diagnostic or treatment procedure deemed necessary by an Emergency physician at a licensed hospital. I understand that any resulting expenses or charges are my responsibility and I will pay them immediately, either directly or through personal insurance.

Parent Signature:

Date:

Parent(s)/Guardian Name:

Phone:

Cell:

Work:

Swimmer’s Physician:

Phone:

Insurance Company:

Policy #:

Allergies/Medical Conditions:

Current Medications:

Emergency Contact. Please list two responsible parties that may be called in the event the parents
cannot be reached.

Name 1:

Relationship 1:

Phone 1:

Name 2:

Relationship 2:

Phone 2:

Notes: