NBWP Summer 2017 AGE GROUP Registration
Our 2017 Summer Season is hosted in partnership with Baker Demonstration School. Please complete all sections of this form. This form contains our mandatory registration, emergency contact and liability release forms. Only athletes who have completed this registration will be allowed to participate. If you have any questions about the online submission, please do not hesitate to contact us at AgeGroup@NorthBeachWaterPolo.com or 847-833-0815.
Practices are held Mondays & Wednesdays 5:00pm-6:30pm at Baker Demonstration School. The first Summer practice is Monday, June 5th and the final practice for the Summer season is on Wednesday, August 9th. The online calendar, found under the "Age Group" tab of our website, has been updated with all of our practices, game information will be added as it becomes available.

*** ALL athletes will need to register for American Water Polo ($40 annual membership).
http://www.americanwaterpolo.org/join-now-

Looking forward to all of you joining us!

Athlete's Name *
Your answer
Nickname
Your answer
Gender
Birth Date
Please enter athlete's birth date xx/xx/xxxx
Your answer
School
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Athlete Email Address
Your answer
Athlete Cell Phone #
Your answer
Home Street Address
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City
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Zip Code
Your answer
Home Phone #
Your answer
Parent 1 Name
Your answer
Parent 1 Email Address
Your answer
Parent 1 Cell Phone #
Your answer
Parent 1 Cell Phone #
Your answer
Parent 2 Name
Your answer
Parent 2 Email Address
Your answer
Parent 2 Cell Phone #
Your answer
EMERGENCY INFORMATION / MEDICAL RELEASE
Though we do not expect there to ever be a problem, we must have all of this information just in case. We want to make sure your kids are always safe and protected!
Emergency Contact Name
Your answer
Emergency Contact Phone #
Your answer
Relationship
Your answer
Insurance Company
Your answer
Insurance Phone Number
Your answer
Group / Policy Number
Your answer
ID #
Your answer
PCP
Your answer
What hospital/affiliation
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Physician's Phone Number
Your answer
Medical Conditions (Please indicate ANY medical conditions: allergic reactions, contact lenses, asthma, previous injuries, current medications ((and why)), etc.)
Your answer
Parent/Guardian Consent
I give my consent/permission to any supervising coach of North Beach Water Polo Club, and the right, on my behalf and in my stand, to arrange for licensed and certified physicians, nurses and/or athletic trainers to render and provide immediate treatment to my child as to injuries that may be sustained by my child while participating in any practices, contests or other activities for North Beach Water Polo, whether directly or indirectly, and whether sustained during practice or in active interscholastic competitions, and without any further or additional authorization by me. My permission and consent also extends to the right of any such supervising coach or North Beach Water Polo personnel to arrange for immediate medical treatment by a licensed or certified physician, nurse, and/or athletic trainer, and for them to apply such emergency medical techniques to my child where, in their judgement, it is deemed appropriate by reason of any injury sustained by my child.
Required
Parent/Guardian giving consent
Your answer
WAIVER AND RELEASE OF ALL CLAIMS FOR PARTICIPATION IN NORTH BEACH WATER POLO, LLC AND BAKER DEMONSTRATION SCHOOL
Name of Participant
Your answer
Please read carefully and be aware that in enrolling and participating in the above program, you will be waiving and releasing all claims for injuries you or the above participant may sustain. As a participant or guardian of a participant in the program, I recognize and acknowledge that there are certain risks of physical injuries, including death, damages or losses which I or the above participant may sustain as a result of his/her participation in any and all activities connected with or associated with such program. I hereby fully release and discharge North Beach Water Polo, LLC, Baker Demonstration School, its members, officers, employees and agents, including the North Beach Water Polo Board and any parent volunteers (hereinafter referred to collectively as “Indemnitees”) from any and all claims from injuries, including death, damages or losses which I or the above participant may sustain or which may accrue on account of participation in the program. I do hereby as a parent or guardian or participant specifically release and discharge the Indemnitees from any causes of action I may have as a parent or guardian for support, mental or emotional damage or otherwise arising out of my relationship to the participant. I further agree to indemnify and hold harmless and defend the Indemnitees from any and all claims resulting from injuries, including death, damages and losses sustained by me or the above participant and arising out of, connected with, or in any way associated with the activities of the program. As a participant in this program, I also agree as a condition of my continued participation to act responsibly and adhere to all policies, rules and restrictions established by North Beach Water Polo, LLC, Baker Demonstration School and the Illinois High School Association. By signing below I acknowledge that I know, understand, and appreciate the potential dangers associated with my participation in the Program and use of Baker’s facilities in connection with the Program. These hazards may include, but are not limited to, minor scrapes, strains, and bruises, as well as significant injuries such as bodily injury, medical conditions, scrapes, strains, paralysis, eye injury, concussions, fractures, drowning and property loss or damage. If I elect to participate in the Program, I do so voluntarily and totally at my own risk.
By initialing below, I am stating that I fully understand the nature of the above Program and this Waiver and Release of All Claims. I also acknowledge that I have had the opportunity to consult legal counsel about the terms of this Waiver and Release.
Your answer
Name of Consenting Guardian
Your answer
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