2018 North Springfield Swim Registration Form for Swim, Dive, and Little Flippers
This form must be completed prior to participating in NSSC Swim, Dive, or Little Flippers teams activities. Please complete one form per child.
Child Last Name *
Your answer
Child First Name *
Your answer
Child Date of Birth *
MM
/
DD
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YYYY
Child's Age as of June 1, 2017 *
Your answer
Parent 1 Full Name *
Your answer
Parent 1 Email Address *
Your answer
Parent 1 Phone Number *
Your answer
Parent 2 Full Name
Your answer
Parent 2 Email Address
Your answer
Parent 2 Phone Number
Your answer
Emergency Contact 1 Name (other than parent) *
Your answer
Emergency Contact 1 Relationship to Child *
Your answer
Emergency Contact 1 Phone Number *
Your answer
Emergency Contact 2 Name (other than parent)
Your answer
Emergency Contact 2 Relationship to Child
Your answer
Emergency Contact 2 Phone Number
Your answer
Do you consent to any necessary emergency medical care for your child, should the need arise, in the event that you, or your emergency contacts, cannot be immediately reached? *
Insurance Carrier
Your answer
Insurance ID Number
Your answer
Primary Physician
Your answer
Primary Physician Phone Number
Your answer
Does your child have any conditions that would require special attention or instruction? All children are welcome to participate. If "Yes" is checked, we will contact you personally for more details.
Please indicate all activities you are registering your child for: *
Required
Please indicate any meets that your child will NOT be available to SWIM at *
Required
The swim team heavily relies on parent volunteers. By selecting positions below you are not committing to specific dates, but joining a pool of parents willing to undertake specific activities. More information will be provided at the parent information meeting. Please select any you would be willing to consider. I would be willing to volunteer for the following positions: *
Required
Please indicate any meets that your child will NOT be available to DIVE at *
Required
The dive team heavily relies on parent volunteers. By selecting positions below you are not committing to specific dates, but joining a pool of parents willing to undertake specific activities. More information will be provided at the parent information meeting. Please select any you would be willing to consider. I would be willing to volunteer for the following positions: *
Required
As Parent/Guardian of the above-name minor(s), I grant permission for the swimmer(s) to participate in all activities of the Swim/Dive/Little Flippers Team, a Northern Virginia Swimming League (NVSL) member team. I represent and warrant that my minor child/children participating on the Swim/Dive/Little Flippers Team are in good health and have no physical condition, ailment or disability which renders them unable to participate in vigorous physical activity. For and in consideration of benefits derived from participation in the Swim/Dive Team/Little Flippers program, I understand that the risk of injury to my child from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist. I assume all risks and hazards arising out of, or related to, such participation, including, but not limited to, transportation to and from such activities, and do hereby indemnify, release and hold harmless the Swim/Dive/Little Flippers Team, its coaches, team representatives, volunteers, property manager, employees and agents, as well as the Northern Virginia Swimming League, from all claims of any kind whatsoever which may arise or hereafter accrue in connection with my child’s/children’s participation in activities of the Swim/Dive/Little Flippers Team. I further grant permission for first aid to be given to my child/children in an emergency, and will be solely responsible for any medical costs which may arise. I AGREE THAT THEY WILL ABIDE BY THE NORTHERN VIRGINIA SWIMMING LEAGUE CODE OF CONDUCT. *
Required
I understand that for my child to participate in the Swim, Dive, and/or Little Flippers Teams, I will have to pay the activity participation fee required by North Springfield Swim Club. *
Required
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