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CAJBC Y Swim Team Registration Information for Fall 2008 – 2009 Season Child/Swimmer’s Name: ___________________________________________ Gender: ____ Age: ______ Date
of Birth: _____/_____/_____ Grade: Address: ______________________________________________________________________ Home Phone: ______________________________ Cell Phone: __________________________ Parent or Guardian Name(s): ____________________________________________________ Address (If different from above): __________________________________________________ Home Phone (If different from above):____________________ Cell Phone: ________________ Cell Phone carrier if you wish to receive text messages: _________________________________ E-mail address (please print clearly): ______________________________________________ Information practice and policy: To
improve communications, we began an e-mail distribution list – sending out
items of interest such as meet results.
The feedback to date has been very positive. We are expanding that this year to include
other items of swim team interest. We
only use the list for swim team communications. Those who are on the list will note we use
“bcc” to prevent inadvertent replies to everyone. We
encourage you to provide an e-mail address if possible – it improves our
communications and lowers our costs. Please check one: _____ I currently have a membership obtained directly through the YMCA. Expiration date: _____/_____/_____ Please provide us with a copy of your card and the method of payment to the YMCA to ensure accuracy of records: 0 SSAP Counselor (Summer Sports Activity Program) 0 YMCA Volunteer 0 Employer Payroll Deduction 0 Other _____ I will purchase a Y membership through the swim team
(please fill out a Y membership card and
place it in the white money box at the pool). _____ I will renew a Y membership through the swim team (please fill out a Y membership card and place it in the white money box at the pool). Expiration date of current card: _____/_____/_____ If you are a US Number: ___________________________________ Expiration date: _____/_____/_____ Page 1 of 4 CAJBC Y Swim Team Emergency Consent Information for Fall 2008-2009
Season Child/Swimmer’s Name: ________________________________________________________ Parent/Guardian name(s) and
place(s) of Employment: 1. _______________________________________ 2.
_________________________________________ _________________________________________ _________________________________________ Phone:
___________________________________ Phone: ____________________________________ Cell Phone:
_______________________________ Cell Phone:
________________________________ Friend or relative who will
assume temporary care of your child if you cannot be reached: Name:
___________________________________
Relationship: _______________________________ Address:
_____________________________________________________________________________ Phone:
___________________________________
Cell Phone: ________________________________ MEDICAL INFORMATION (MUST BE COMPLETED) Child’s Physician:
___________________________ Physician’s Phone: ________________________ Preferred Hospital:
___________________________________________________________________ Health Insurance Carrier:
_____________________________________________________________ Policy Holder’s Name:
_____________________________ Policy Number:_____________________ Health Information: Please list any health conditions or
chronic condition that your child may have Medication your child is taking for
any of the above conditions: ______________________________ My child has had a physical in the
past 12 months: _____ Date: _____/_____/_____ I authorize the coaches or
parent officers of the CAJBC Y Swim Team to contact person(s) named on this
paper and authorized named physician(s) to render such treatment as may be
deeded necessary in an emergency. In
the event person(s) named above cannot be contacted, CAJBC Y Swim Team
coaches and parent officers are authorized to take whatever action is deemed
necessary in their judgment for the health of the above-named child. I will not hold the JB Chambers YMCA, the
CAJBC Y Swim Team, its coaches or officers financially responsible for the
emergency care and/or transportation of the above-named child. Parent/Guardian Signature: ____________________________________
Date: _____/_____/_____ Page 2 of 4 CAJBC Y Swim Team T-Shirt Information for Fall 2008-2009 Season DEADLINE FOR T-SHIRT ORDER FORMS IS Each swimmer receives a
team shirt with their paid fees. At
times, other swim teams provide shirts for participation in invitationals, etc.
Please complete the information to allow ordering of shirts throughout
the season easily accomplished. Swimmer’s Name
______________________________________________________________ T-Shirt Size (Circle
One): YM YL AS AM Additional Shirts (CAJBC Y
team shirts only): Indicate # of shirts wanted
by each size. ______ YM (@ $12.00) ______
YL
(@ $12.00) ______
AS
(@ $12.00) ______
AM (@ $12.00) ______
______
______
AXXL (@ $13.00) Total number of shirts
(include swimmers) : __________ Total enclosed (only if ordering
additional shirts): $___________ Payment for additional shirts must accompany
order. Make checks payable to: CAJBC Y
Swim Team. Page 3 of 4 CAJBC Y Swim Team Photo Publication for Fall 2008 – Summer 2009 Season This section grants permission
for the use of your child’s likeness for team promotions. This may be pictures for the newspaper or
on the team website. Please note, on
the website, www.cardinalaquatics.com,
no identifying information will accompany the photo. The kids like seeing themselves and friends
on the site so we hope you will consider granting permission below. Thank you. Parent/Guardian Consent For Possible Publication of
Team Photos: I hereby o
Grant o
Deny permission to the CAJBC Y
Swim Team to use my child’s photograph for the 2008-2009 season without
further consideration, and I acknowledge the team’s right to crop the
photograph at its discretion. No names
will be used, only pictures. I also
understand that once my child’s image is captured and used, the image can be
used to promote the CAJBC Y Swim Team.
Therefore, I agree to indemnify and hold harmless from the CAJBC Y
Swim Team, its officers and staff. Swimmer’s Name
________________________________________________ Parent/Guardian Signature
_________________________________________ Date __________________ Page 4 of 4 |