(one form for each child must be completed)

 

Last name                                             First name                                       MI __

 

Preferred Name                                      DOB ____________  Age _____  M / F _____

 

Address                                                                              

City                                      State_______ zip ____________
 

Parents Name _____________________________
 

Home # __________________

 

Wk # ________________________________( M / F )   Cell # ______________( M / F )

 

Emergency # _________________________  email address ____________________

 

Were you a swimmer on another USS Swim team? _____ When? _______________ 

If so, what was the name?______________________  Team Abbreviation ______.

 

I, _____________________________ agree to release Youth Swimming, Inc.,  Walton Waves, Inc. , Youth Athletic Recreation Company, Inc., & Staff, Bluesprings Sports Ranch & Staff from any responsibility for property damage, illness, or injury incurred by my child at Bluesprings. I agree to allow Walton Waves Swimming Staff, or another authority to administer First Aide for my child, if necessary. I, the undersigned, will be responsible for any & all costs of medical attention and/or treatment.

 Website information: Swimmers names and pictures may appear on or through our website - www.waltonwaves.com  in the form of meet entries, meet results, rosters, as well as team pictures and action photos.

Signed _________________________Date __________________ 

            Please make checks payable to : WALTON WAVES

You can mail registration form to: Walton Waves

                                                                                        1810 Kristins Way

                                                                                        Loganville, Georgia 30052

OR bring by pool M-F, 4-6pm.

If you have any further questions please call (770) 466-8353

 

 
 

 

 

  

 

 MEDICAL HISTORY AND RELEASE FORM

 

Name:                                             Parents:                                                     

Check if your child has had any of the following:

 

�  cardiac problems                              �  asthma                                 �  chronic ear problems 

�  seizures                                           �  diabetes                               �  chronic illness

 

If any of the above is checked, please provide a statement from the treating physician clearing the child for swim team participation.

 

Describe any other health problem not listed above:                                                                                                

List  all surgeries:                                                                                                                                       

List all medications he/she is taking:                                                                                                                

List any ALLERGIES (medications &insects):                                                                                                

Physician Name & phone#:                                                                                                                         

 

 

I,                                       (parent/guardian print name) hereby give permission for any and all medical attention to be administered to my child,                                    (child’s name), in the event of accident, injury or sickness, under the direction of the person(s) below, until such time as I may be contacted.  I also assume responsibility for the payment of any such treatment. 

Youth Swimming, Inc.,  Walton Waves, Inc. , Youth Athletic Recreation Company, Inc., & Staff, Bluesprings Sports Ranch & Staff from  will not be held responsible for property damage, illness, or injury incurred by my child at Bluesprings. 

Address                                                                                                                       

Home Phone                                     Work Phone                               

Emergency Contact:   
  Name                                                                                     

                             Phone#                         Relation                               

Insurance Plan & Policy Number:                                                        

In case I cannot be reached, any of the following persons are designated to act on my behalf: 

            *  Coach       * Assistant Coach        * Designee of the Walton Waves Swim Team 

 

Parent/Guardian Signature                                                            Date