Fall Registration Form 2018
Please complete this form to register for the Viper Pigeon Fall Program. Please be sure to select the correct pool location and program.
Athlete Name: *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Which pool will you be participating at? *
Which program will you be participating in? *
Current or Future High School
Your answer
Gender *
Parent Name(s) *
Your answer
Phone Number *
Your answer
Alternate Phone Number
Your answer
E-mail(s) *
seperate multiple e-mails with commas
Your answer
Emergency Contact
Name and number
Your answer
Medical Information
Your answer
I hereby authorize the directors of the West Houston Water Polo Club to act according to their best judgment in any emergency requiring medical attention. I know of no medical, mental, or physical problems, which might affect my MINOR CHILD’s ability to safely participate in this program others then the ones listed above. I will be responsible for any medical and/or other charges in connection with my MINOR CHILD’s attendance at practices or tournaments. I hereby agree to save, indemnify and hold harmless the West Houston Water Polo Club staff, its agents, employees, and sponsors against any and all liability, claims, or demands for damages arising from injuries, illness, or lost or stolen property sustained by my MINOR CHILD during participation with this program. *
Required
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