2019-2020 Optima Synchro Registration Form
Please submit this registration form and mail payment by Monday September 16th or pay online now to confirm your spot on the team.
Swimmer's Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Street address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Home phone # *
Your answer
Parent e-mail (primary) *
Your answer
Parent e-mail (secondary)
Your answer
Swimmer's e-mail (optional)
if you would like them to be included on team communcations
Your answer
Mother's full name *
Your answer
Mother's cell # *
Your answer
Mother's work phone
Your answer
Father's full name *
Your answer
Father's cell # *
Your answer
Father's work phone
Your answer
In the event of practice cancellation or change, coaches may provide text updates/notification. *
Please check cell number(s) to be used for text communication.
Required
I authorize Optima Synchro to obtain, store, and/or use (without payment) any photographs, slides, and/or videotapes of my child for public relations, marketing/advertising, and/or internal training purposes. *
Required
If yes, please initial below.
Your answer
Emergency Information
Emergency contact (other than a parent/guardian) *
First & last name
Your answer
Phone # *
Your answer
Relationship to child
Your answer
Child's physician *
Your answer
Physician phone # *
Your answer
Child's dentist *
Your answer
Dentist phone # *
Your answer
Insurance Company *
Your answer
Insurance ID or policy # *
Your answer
Health history
List any chronic conditions, operations, injuries or medications:
Your answer
List any dietary restrictions, allergies, reactions and treatment:
Your answer
Is there documentation of a physical exam, immunization record, and lead screening on file at your child's school? *
Required
If Yes, please inital below:
Your answer
Emergency Authorization
I hereby give permission for the coaches of Optima Synchro to provide first aid treatment to my child (named above) when necessary. In the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I understand that Optima Synchro personnel will make every effort to contact me regarding any emergency involving my child.
Parent/guardian signature *
Full name
Your answer
Date *
MM
/
DD
/
YYYY
Payment
Registration and payment are due Моnday, September 16th.*
For your convenience, you may pay via the PayPal button on the Parent Page.
- or -
If you prefer to mail payment or pay in full, please make check payable to Optima Aquatics and mail to:
Svetlana Malinovskaya, 168 River Road #317, Andover, MA 01810.
*Please note that registration is complete once payment has been received.
Please select your payment option below: *
Required
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