ESWP Age Group 2018-2019 Winter Registration
The 2018-2019 Winter Season is hosted in partnership with Evanston High School & Baker Demonstration School. The first winter practice is on Sunday, December 2nd and the final practice for the season is on Sunday, February 24th.
Never played the sport before? No problem! Join us for a practice to find out what the hype is all about.
Please complete all sections of this form. This form contains our mandatory registration, emergency contact and liability release forms. Only athletes who have completed this registration will be allowed to participate. If you have any questions about the online submission, please do not hesitate to contact us at Jimmy@EastSideWaterPolo.org or 847-833-0815.
Practices will be held at Baker and ETHS.
The complete fall schedule can be found at https://eastsidewaterpolo.org/age-group/schedule - the game schedule will be released closer to the start of season.

PAYMENT INFORMATION:
Winter 2018-2019: December 2nd - February 24th (10 weeks)
$400 - Check or Chase QuickPay via Jimmy@EastSideWaterPolo.org Please write the members name(s) on the memo line. Checks made payable to "East Side Water Polo."
Due on or before Wednesday, 1/13/19.

• Please do not hesitate to email Jimmy in regards to financial aid and/or payment plans. Jimmy@EastSideWaterPolo.org

*** ALL athletes will ALSO need to register for American Water Polo ($50 annual membership. ). http://www.americanwaterpolo.org/join-now-

* Required

Athlete Name *
Your answer
Nickname
Your answer
Gender *
Birthday *
MM
/
DD
/
YYYY
Shirt Size (Adult Unisex) *
School *
Your answer
What is your American Water Polo Membership ID? *
AWP offers a 12 month membership, make sure to check and see if your membership is still active. If not you will need to visit americanwaterpolo.org and register/re-register before signing up for East Side Water Polo.
Your answer
What position do you play? *
Athlete Email Address *
Your answer
Athlete Cell Phone # *
Your answer
Parent 1 First Name *
Your answer
Parent 1 Last Name *
Your answer
Parent 1 Email Address *
Your answer
Parent 1 Phone # *
Your answer
Parent 2 First Name *
Your answer
Parent 2 Last Name *
Your answer
Parent 2 Email Address *
Your answer
Parent 2 Phone # *
Your answer
Home Address *
Your answer
Emergency Information / Medical Release
Though we do not expect there to ever be a problem, we must have all of this information just in case. We want to make sure your kids are always safe and protected!
Emergency Contact Name *
Your answer
Emergency Contact Phone # *
Your answer
Relationship *
Your answer
Insurance Company *
Your answer
Insurance Company Phone # *
Your answer
Group / Policy # *
Your answer
ID # *
Your answer
Primary Care Physician *
Your answer
Hospital / Affiliation *
Your answer
Physician's Phone # *
Your answer
Medical Conditions *
Please indicate ANY medical conditions: allergic reactions, contact lenses, asthma, previous injuries, current medications (and why), etc.
Your answer
East Side Water Polo, LLC Photo, Video & Social Media Release
In an effort to promote ESWP, we have created an Instagram handle (eastsidewp) and a Facebook page (eastsidewaterpolo).
The content: Recognizing individual/team achievements, promoting local and national events, photos or videos of practices/games/tournaments/scrimmages
East Side Water Polo, LLC will use photographs and/or videos and quotations from our members in our website and social media pages. These photos, videos and quotations are never associated with the full name of the member. Photos, videos and quote are used solely to promote ESWP. *
Parent / Guardian Consent *
Parent / Guardian Consent: *I give my consent/permission to any supervising coach of East Side Water Polo Club, and the right, on my behalf and in my stand, to arrange for licensed and certified physicians, nurses and/or athletic trainers to render and provide immediate treatment to my child as to injuries that may be sustained by my child while participating in any practices, contests or other activities for East Side Water Polo, whether directly or indirectly, and whether sustained during practice or in active interscholastic competitions, and without any further or additional authorization by me. My permission and consent also extends to the right of any such supervising coach or East Side Water Polo personnel to arrange for immediate medical treatment by a licensed or certified physician, nurse, and/or athletic trainer, and for them to apply such emergency medical techniques to my child where, in their judgement, it is deemed appropriate by reason of any injury sustained by my child.
Parent / Guardian Full Name Giving Consent *
Your answer
WAIVER AND RELEASE OF ALL CLAIMS FOR PARTICIPATION IN EAST SIDE WATER POLO, LLC
Name of Participant *
Your answer
Please read carefully and be aware that in enrolling and participating in the above program, you will be waiving and releasing all claims for injuries you or the above participant may sustain. As a participant or guardian of a participant in the program, I recognize and acknowledge that there are certain risks of physical injuries, including death, damages or losses which I or the above participant may sustain as a result of his/her participation in any and all activities connected with or associated with such program. I hereby fully release and discharge East Side Water Polo, LLC, its members, officers, employees and agents, including the East Side Water Polo Board and any parent volunteers (hereinafter referred to collectively as “Indemnitees”) from any and all claims from injuries, including death, damages or losses which I or the above participant may sustain or which may accrue on account of participation in the program. I do hereby as a parent or guardian or participant specifically release and discharge the Indemnitees from any causes of action I may have as a parent or guardian for support, mental or emotional damage or otherwise arising out of my relationship to the participant. I further agree to indemnify and hold harmless and defend the Indemnitees from any and all claims resulting from injuries, including death, damages and losses sustained by me or the above participant and arising out of, connected with, or in any way associated with the activities of the program. As a participant in this program, I also agree as a condition of my continued participation to act responsibly and adhere to all policies, rules and restrictions established by East Side Water Polo, LLC and the Illinois High School Association. By signing below I acknowledge that I know, understand, and appreciate the potential dangers associated with my participation in the Program. These hazards may include, but are not limited to, minor scrapes, strains, and bruises, as well as significant injuries such as bodily injury, medical conditions, scrapes, strains, paralysis, eye injury, concussions, fractures, drowning and property loss or damage. If I elect to participate in the Program, I do so voluntarily and totally at my own risk. * *
By initialing below, I am stating that I fully understand the nature of the above Program and this Waiver and Release of All Claims. I also acknowledge that I have had the opportunity to consult legal counsel about the terms of this Waiver and Release.
Your answer
Name of Consenting Guardian *
Your answer
Comments
As always if you have any comments or questions, please do not hesitate to reach out to me directly by email or phone (listed below). Jimmy Heard Jimmy@EastSideWaterPolo.org 847-833-0815
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of East Side Water Polo. Report Abuse - Terms of Service