2018 ASA Aquadogs Emergency Contact Information
Swimmer Information
Swimmer's First Name *
Your answer
Swimmer's Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Parent's/Guardian's Information
Parent or Guardian Name *
Parent/Guardian #1
Your answer
Email *
Parent/Guardian #1 Email Address
Your answer
Cell Phone *
Cell phone number for Parent/Guardian #1
Your answer
Home Phone
Home phone number for Parent/Guardian #1
Your answer
Work Phone
Work phone number for Parent/Guardian #1
Your answer
Address *
Please include Street Address, City, State, and Zip Code for Parent/Guardian #1 (Example: 1234 Main Street, Kirksville, MO 63501)
Your answer
Parent/Guardian Name *
Parent/Guardian Name for parent #2
Your answer
Email
Parent/Guardian #2 Email Address
Your answer
Cell Phone
Cell phone number for Parent/Guardian #2
Your answer
Home Phone
Home phone number for Parent/Guardian #2
Your answer
Work Phone
Work phone number for Parent/Guardian #2
Your answer
Address
Please include Street Address, City, State, and Zip Code for Parent/Guardian #2 (Example: 1234 Main Street, Kirksville, MO 63501)
Your answer
Primary Emergency Contact
Primary Emergency Contact Name *
Please tell us who we can contact in the event of an emergency when parent's/guardian's are not able to be reached.
Your answer
Relation to Swimmer *
Please describe how the Primary Emergency Contact is related to the swimmer. (i.e. Grandmother, Aunt, Uncle, Family Friend, etc.)
Your answer
Cell Phone *
Cell phone number for Primary Emergency Contact
Your answer
Home Phone
Home phone number for Primary Emergency Contact
Your answer
Work Phone
Work phone number for Primary Emergency Contact
Your answer
Address
Please include Street Address, City, State, and Zip Code for Primary Emergency Contact (Example: 1234 Main Street, Kirksville, MO 63501)
Your answer
Secondary Emergency Contact
Secondary Emergency Contact Name
Please tell us who we can contact in the event of an emergency when parent's/guardian's and primary emergency contact are not able to be reached.
Your answer
Relation to Swimmer
Please describe how the Secondary Emergency Contact is related to the swimmer. (i.e. Grandmother, Aunt, Uncle, Family Friend, etc.)
Your answer
Cell Phone
Cell phone number for Secondary Emergency Contact
Your answer
Home Phone
Home phone number for Secondary Emergency Contact
Your answer
Work Phone
Work phone number for Secondary Emergency Contact
Your answer
Address
Please include Street Address, City, State, and Zip Code for Secondary Emergency Contact (Example: 1234 Main Street, Kirksville, MO 63501)
Your answer
Allergies/ Health Considerations
Please list any allergies and/or special health considerations in case of an emergency
Your answer
Permission
I give permission for my child to participate in swim practices and meets. I release ASA Aquadogs and individuals from liability in case of accident during activities related to ASA Aquadogs, as long as normal safety procedures have been taken.
Parent's/Guardian's Signature
Please type in your name to confirm that the above statement is true.
Your answer
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