Summer Try It! with Fraser Valley Water Polo
Registration
Athlete Last Name: *
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Athlete First Name: *
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Date of Birth:
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Gender: *
Athlete Address: *
Example: 12354 56 Ave
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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
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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
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Other Phone Number:
Example: 123.456.7890
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Emergency Contact other than parent: *
Please Include First and Last Name
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Emergency Contact Phone Number: *
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Athlete Relevant Medical Information including Allergies: *
If this is not applicable, please indicate with N/A
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Medications *
Please list any medications the athlete is taking. If this is not applicable, indicate with N/A
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Is athlete able to self-administer medications?
If NO, do you authorize a Chaperone to give medication?
Do you authorize a Chaperone to give over the counter pain medication?
If YES, please indicate which medication (ie: Advil, Tylenol, etc)
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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.
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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? *
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