Hammerhead Swim Club

2009-2010 Swimmer Information/Medical Release

PLEASE PRINT and COMPLETE ONE (1) FORM FOR EACH CHILD/SWIMMER

Swimmer’s Name: ___________________________

Birth Date: ________________ Gender: _____________

Address: _____________________________________________

Cit, State, Zip: _________________________________________

Parents Names: _________________________________________

Parents Work #: ________________________________________

Email Address (es): ______________________________________

VERY IMPORTANT – please be sure we have your emails that you check regularly. This is how we communicate…..

Emergency Contact Name/phone #: __________________________________

Dr’s. Name and Phone #: ___________________________________________

Health Insurance: _________________________________________________

Policy #: ____________________________ Group #: ____________________

Allergies: ________________________________________________________

Medicines: _______________________________________________________

In the event of injury or illness, if I am unavailable to be reached, I hereby give permission for immediate care and transportation to be provided for the child named on this page.

Signed: _______________________________________ Date: ______________

Relationship: ____________________ Telephone Number: _________________