FALL 2019 REGISTRATION FORM
Season: August 5th - October 26th
Practice: 12U and 14U Monday/Wednesday 6:30-8:00
Practice: 16U and 18U Monday/Tuesday/Thursday 6:30-8:30
Practice Location: Washington City Community Center
Registration Due: August 19th
Registration form must be filled our prior to the first day of practice.
All athletes must have a current Bronze membership with USA Water Polo affiliated with SUWP
Games/Scrimmage season calendar will be available August 5th at parent meeting from 6:30-7 at WCCC
Last/First Name *
Your answer
Athlete T-shirt size
Athletes age as of August, 1 2019 *
Your answer
Athlete Grade (Fall 2019) *
Your answer
Athlete High School boundary (current or future) *
USA Water Polo membership number(6 digit #) For insurances purposes, ALL athletes need a Bronze membership through USA Water Polo affiliated with Southern Utah Water Polo. Include a current photo with membership ID *
Your answer
Primary Contact Name(First/Last) *
Your answer
Primary Contact Email *
Your answer
Primary Contact Phone Number *
Your answer
Primary Contact - Relationship to Athlete *
Athlete Contact - Email or Phone# (Optional)
Your answer
Informed Consent, Release Agreement, and Authorization
I understand that participation in the team sport of water polo involves the risk of personal injury. I also understand that participation in the team sport of water polo is entirely voluntary and requires participants to follow instructions and abide by all applicable rules. In case of an emergency involving my child, I understand that efforts will be made to contact the individual(s) listed as the primary and emergency contacts by the Coach and or medical provider. In the event that these individuals cannot be reached, permission is hereby given to the medical provider to secure proper treatment for my child.

With appreciation of the dangers and risks associated with participating in water polo activities, on my own behalf and behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against Southern Utah Water Polo, their Coaches, employees, volunteers, coordinators, related parties, or other organizations associated with the team sport of water polo and its associated activities.

I also hereby grant Southern Utah Water Polo as well as their authorized representatives, the right and permission to use and publish photographs/film/videotapes/electronic representations and/or sound recordings made while my child is participating in the team sport of water polo and its associated activities. I hereby release Southern Utah Water Polo, their Coaches, employees, volunteers, coordinators, related parties, or other organizations associated with the team sport of water polo and its associated activities from any and all liability from such use and publication and I specifically waive any right to any compensation I may have for any of the foregoing.
Informed Consent, Release Agreement Waiver: *
Authorization accepted by (type name) *
Your answer
Fall Season Junior (12U/14U) participation fee is $160.00 due by August 19th. *
Fall Season Senior (16U/18U) participation fee is $210.00 due by August 19th. *
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