ESWP High School 2018-2019 Winter Season Registration
The 2018-2019 High School Winter Season at ESWP is almost here. The season runs from November 26th through February 20th and promises to an AWESOME ONE! With practices 4-5 days a week and weekend tournaments, there is no better place to take your game to the next level! Below you will find our online registration form. All participants MUST fill this out! If you do not fill out this form, you will not receive email updates/information and you will not be allowed to participate in games or practices.

This season we will be offering:
- Field Player & Goalie Training
- 4-5 water practices a week
- Games/Tournaments
- Team Tactic Development
- Individual Skill Development
- Strength and Speed Development
- Strength & Conditioning 2x a week
- Chalk Talks/Game Film

Practice Location:
All practices take place @ Evanston High School - 1600 Dodge Ave, Evanston, IL 60201.
The pool is directly across the street from 1603 Dodge Ave., Evanston, IL 60201.

Tournament/Game Information:
The winter season will include weekend (Saturday and/or Sunday) tournaments and scrimmages.
The full season schedule can be found online at.... https://eastsidewaterpolo.org/high-school/schedule2
(THE GAME SCHEDULE is not finalized yet, but will be on the website by 11/28/18)

Club Sports/Activities:
For those of you participating in other sports/clubs/activities; we welcome you! Organize your schedule and plan on attending East Side practices on Monday's AND/OR Wednesday's. That will allow you to swim/participate in other clubs or sports on Tuesday/Thursday/Friday+the weekend. Please contact Jimmy directly if you have conflicts due to another sport or club commitment, and would like additional information.

PAYMENT INFORMATION:
Winter 2018-2019: November 26th - February 20th (10 weeks)
$525 - Check or Chase QuickPay. Please write the members name(s) on the memo line. Checks made payable to "East Side Water Polo"

• 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 First Name *
Your answer
Athlete Last Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Graduation Year *
Shirt Size (Unisex Sizes) *
Your answer
Gender *
What high school do you attend? *
Your answer
What team did you play on? *
What position do you play? (primarily) *
What is your American Water Polo Membership ID? *
AWP offers a 12 month membership, contact AWP to find out 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
Brief Tournament Questionnaire
Most tournament will be 30-45 minutes away.
I am willing to travel to tournaments... *
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
Home Phone # *
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/current injuries**, current medications, 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
I, the guardian of _________ (member full name) *
Your answer
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 (ATHLETE) *
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. (Just Guardian Initials)
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
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