ASA Aquadogs Emergency Contact Information
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Swimmer Information
Swimmer's First Name *
Swimmer's Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Parent's/Guardian's Information
Parent or Guardian Name *
Parent/Guardian #1
Email *
Parent/Guardian #1 Email Address
Cell Phone *
Cell phone number for Parent/Guardian #1
Home Phone
Home phone number for Parent/Guardian #1
Work Phone
Work phone number for Parent/Guardian #1
Address *
Please include Street Address, City, State, and Zip Code for Parent/Guardian #1 (Example: 1234 Main Street, Kirksville, MO 63501)
Parent/Guardian Name *
Parent/Guardian Name for parent #2
Email
Parent/Guardian #2 Email Address
Cell Phone
Cell phone number for Parent/Guardian #2
Home Phone
Home phone number for Parent/Guardian #2
Work Phone
Work phone number for Parent/Guardian #2
Address
Please include Street Address, City, State, and Zip Code for Parent/Guardian #2 (Example: 1234 Main Street, Kirksville, MO 63501)
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.
Relation to Swimmer *
Please describe how the Primary Emergency Contact is related to the swimmer. (i.e. Grandmother, Aunt, Uncle, Family Friend, etc.)
Cell Phone *
Cell phone number for Primary Emergency Contact
Home Phone
Home phone number for Primary Emergency Contact
Work Phone
Work phone number for Primary Emergency Contact
Address
Please include Street Address, City, State, and Zip Code for Primary Emergency Contact (Example: 1234 Main Street, Kirksville, MO 63501)
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.
Relation to Swimmer
Please describe how the Secondary Emergency Contact is related to the swimmer. (i.e. Grandmother, Aunt, Uncle, Family Friend, etc.)
Cell Phone
Cell phone number for Secondary Emergency Contact
Home Phone
Home phone number for Secondary Emergency Contact
Work Phone
Work phone number for Secondary Emergency Contact
Address
Please include Street Address, City, State, and Zip Code for Secondary Emergency Contact (Example: 1234 Main Street, Kirksville, MO 63501)
Allergies/ Health Considerations
Please list any allergies and/or special health considerations in case of an emergency
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.
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