Beachwood Bison Swim Club Athlete Registration Application

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Athlete's Last Name *

Athlete's Legal First Name *

Athlete's Middle Name *

Athlete's Preferred Name *

Date of Birth *

MMDDYY

Sex *

Age *

Father/Guardian Last Name

Father/Guardian First Name

Mother/Guardian Last Name

Mother/Guardian First Name

Mailing Address *

City *

State *

Zip *

Home Phone Number with Area Code *

Family Email Address *

Disabilities

Legally Blind or Visually Impaired

Deaf or Hard of Hearing

Physical Disability such asamputation, cerebral palsy, dwarfism, spinal injury, mobility impairment

Cognitive Disability such as Mental Retardation, Severe Learning disorder, autism

Race and Ethnicity *

(You may make up to two choices if appropriate)

Black or African American

Asian

White

Hispanic or Latino

American Indian or Alaska Native

Some Other Race

Native Hawaiian or Other Pacific Islander

Required

Are you a member of another FINA federation? *

Yes

If you answered yes, which federation?

Enter the year you were last registered with USA Swimming

If you registered with a different USA Swimming club previously, enter that club's code

Club Name

LSC Code

What was the date of your last competition representing that club?

High School Students - year of high school graduation

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.

Yes

Required

Preferred Physician's Name *

Physician's Phone Number *

Preferred Dentist *

Preferred Hospital

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.

Name of Insurance Company

Insurance Policy Number

Insurance Agent

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.

Yes

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.

Yes

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

Yes

Required

Submit

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