San Jose Express Registration Spring 2019 - all age groups
Athlete Last Name *
Your answer
Athlete First Name *
Your answer
Gender *
Birthdate *
MM
/
DD
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YYYY
Which age group/program are you registering for? (Determined by age prior to 8/1/2019) *
Swim Clinic *
Day(s) of week for swim clinic *
Required
Athletes USAWP Registration Number *
Go to https://webpoint.usawaterpolo.com/wp/memberships/join.wp. please use "Silver Athlete" or "Gold Athlete." Join under San Jose Express Club ID: 25911 .
Your answer
Parent Name 1 *
Your answer
Parent 1 email *
Your answer
Parent 1 phone # (xxx-xxx-xxxx)
Your answer
Parent 2 Name
Your answer
Parent 2 Email
Your answer
Parent 2 phone # (xxx-xxx-xxxx)
Your answer
Player email if over 16
Your answer
Medical Doctor (name, group, phone#)
Your answer
Dentist (name, group phone #)
Your answer
Any medical conditions/allergies? (write none if applicable)
Your answer
I have read "The Team's" parent/player/team contract *
I, the parent/guardian and the registrant, a minor, assume full responsibility and liability as follows: Recognizing the possibility of physical injury associated with water polo and in consideration for San Jose Express Aquatics accepting the registrant for its water polo programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify San Jose Express Aquatics, affiliated organizations, their employees and associated personnel, including the owners of the pools and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. *
Required
San Jose Express Aquatics feels it desirable to provide club coaches with the parents or guardians’ permission to sign the necessary authorization for emergency treatment if it may be necessary. It is understood that in all cases the officials will attempt to secure the advice of the parent by telephone before using the authorization given by this form. This authorization is similar to that which a number of parents furnish to friends or relatives in whose care their children may be left. Our permission is hereby given to the coach or representative of San Jose Express Aquatics to authorize by his or her signature whatever medical or surgical treatment may be considered necessary or advisable by the physician or nurse in attendance in the event of an accident or medical emergency involving my child while participating in the San Jose Express Aquatics program. *
Required
I, the parent/guardian and the registrant, a minor, consent to the use of "The athlete's" image or likeness by San Jose Express Aquatics which may include but is not limited to various social media and promotional materials. *
Required
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