San Jose Express Registration Winter 2016-17 - all age groups
Athlete Last Name
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Athlete First Name
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Gender
Birthdate
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DD
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YYYY
Choose Water Polo Age Group/Program
Swim Clinic Sign Up (11/7 - 1/29)
Required
I expect to attend the swim clinic on the follow days/times (2x or 3x/week)
Athletes USAWP Registration Number
Go to https://webpoint.usawaterpolo.com/wp/memberships/join.wp. please use "Silver Athlete" or "Gold Athlete." Join under San Jose Express Club ID: 25911 .
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Parent 1 name (Full name)
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Parent 1 email
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Parent 1 phone # (xxx-xxx-xxxx)
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Parent 2 Name (Full name)
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Parent 2 Email
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Parent 2 phone # (xxx-xxx-xxxx)
Your answer
Player email if over 16
Your answer
Medical Doctor (name, group, phone#)
Your answer
Dentist (name, group phone #)
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Any medical conditions/allergies? (write none if applicable)
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I have read "The Team's" parent/player/team contract
I, the parent/guardian and the registrant, a minor, assume full responsibility and liability as follows: Recognizing the possibility of physical injury associated with water polo and in consideration for the San Jose Express Water Polo Club LLC accepting the registrant for its water polo programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the San Jose Express Water Polo Club LLC, affiliated organizations, their employees and associated personnel, including the owners of the pools and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.
Required
San Jose Express Water Polo Club LLC feels it desirable to provide club coaches with the parents or guardians’ permission to sign the necessary authorization for emergency treatment if it may be necessary. It is understood that in all cases the officials will attempt to secure the advice of the parent by telephone before using the authorization given by this form. This authorization is similar to that which a number of parents furnish to friends or relatives in whose care their children may be left. Our permission is hereby given to the coach or representative of the San Jose Express Water Polo Club to authorize by his or her signature whatever medical or surgical treatment may be considered necessary or advisable by the physician or nurse in attendance in the event of an accident or medical emergency involving my child while participating in the San Jose Express Water Polo Club program.
Required
I, the parent/guardian and the registrant, a minor, consent to the use of "The athlete's" image or likeness by San Jose Express LLC which may include but is not limited to various social media and promotional materials.
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