Beachwood Bison Swim Club Athlete Registration Application
Athlete's Last Name *
Your answer
Athlete's Legal First Name *
Your answer
Athlete's Middle Name *
Your answer
Athlete's Preferred Name *
Your answer
Date of Birth *
MMDDYY
Your answer
Sex *
Age *
Your answer
Father/Guardian Last Name
Your answer
Father/Guardian First Name
Your answer
Mother/Guardian Last Name
Your answer
Mother/Guardian First Name
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Home Phone Number with Area Code *
Your answer
Family Email Address *
Your answer
Disabilities
Race and Ethnicity *
(You may make up to two choices if appropriate)
Required
Are you a member of another FINA federation? *
If you answered yes, which federation?
Your answer
Enter the year you were last registered with USA Swimming
Your answer
If you registered with a different USA Swimming club previously, enter that club's code
Your answer
Club Name
Your answer
LSC Code
Your answer
What was the date of your last competition representing that club?
Your answer
High School Students - year of high school graduation
Your answer
Medical Consent *
I hereby give my consent for: (1) the administration of any treatment deemed necessary by the physician listed below or, in the even the designated preferred practitioner is not available, by another licensed physician or dentist and (2) the transfer of the child to the preferred hospital listed below, or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Required
Preferred Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Preferred Dentist *
Your answer
Preferred Hospital
Your answer
Allergies, medication and medical history
Give accurate, up-to-date facts concerning the child's medical history, health status, allergies and medications. Facts concerning the child's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted.
Your answer
Name of Insurance Company
Your answer
Insurance Policy Number
Your answer
Insurance Agent
Your answer
To Grant Consent *
In case of injury, while participating in interscholastic athletics, we parents/guardians of the above named student, will not hold Beachwood Swimming or any of the school personnel responsible for medical costs.
Required
Acknowledgement of Warning by Parents *
We/I the parent(s) do hereby acknowledge that we/I have been fully advised, cautioned and warned by the proper administrative and coaching personnel of the Beachwood Bison Swim Club that our/my child named above may suffer serious injury, including but not limited to, the risk of sprains, fractures and ligament and/or cartilage damage which could result in a temporary or permanent, partial or complete, impairment in the use of the child's limbs; brain damage; paralysis; or even death by participating in the sport of swimming. Notwithstanding such warnings and with full knowledge which may result, we/I give our/my consent to the child mentioned above to participate in the sport of swimming and understanding of the risk of serious injury to which I am exposing my child by participating in the above sport.
Required
Code of Conduct *
Please check yes when you have read the code of conduct, which can be found at this link: http://www.beachwoodbisonswimclub.com/uploads/BHSParentStudentHandbook20192010REV.pdf
Required
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