Summer Try It! with Fraser Valley Water Polo

Registration

Athlete Last Name: *

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Athlete First Name: *

Your answer

Date of Birth:

YYYY

Gender: *

Female

Male

Other:

Athlete Address: *

Example: 12354 56 Ave

Your answer

City: *

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Postal Code: *

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Athlete BC Care Card Number: *

Example: 1234 5678 909

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Parent/Guardian Name: *

Please Include First and Last Name

Your answer

Email to be added to team contact list: *

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Second email if desired:

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Home Phone Number: *

Example: 123.456.7890

Your answer

Other Phone Number:

Example: 123.456.7890

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Emergency Contact other than parent: *

Please Include First and Last Name

Your answer

Emergency Contact Phone Number: *

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Athlete Relevant Medical Information including Allergies: *

If this is not applicable, please indicate with N/A

Your answer

Medications *

Please list any medications the athlete is taking. If this is not applicable, indicate with N/A

Your answer

Is athlete able to self-administer medications?

Yes

If NO, do you authorize a Chaperone to give medication?

Yes

Do you authorize a Chaperone to give over the counter pain medication?

Yes

If YES, please indicate which medication (ie: Advil, Tylenol, etc)

Your answer

I/We, the parent(s)/guardian(s) confirm the above information to be accurate and can be used for emergency purposes. *

Please enter your full name in the box as a digital signature.

Your answer

FVWP, the PSO & NSO (Water Polo Canada) have a valid interest in taking photographs, video or digital recordings of games and players during regular practice and competitive water polo activities. These could be used to promote the club & sport of water polo on any digital or print media. I am aware that consenting to this I am permitting my player's name, photos & performance to be used for media and promotional reasons. Do you consent to the above statement? *

Yes

I'd like more information

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