WILLITS

 OTTERS  SWIM  TEAM  

REGISTRATION/EMERGENCY  CARD      

SWIMMER  INFORMATION  

LAST  NAME:  ___________________________  FIRST  NAME:  _________________________  MI  _____________  

DATE  OF  BIRTH  (MM/DD/YYYY)  ________/________/________                            GENDER        □  MALE          □  FEMALE  

CITIZENSHIP:        □      US  CITIZEN      □      DUAL  CITIZEN      □      OTHER  (PLEASE  SPECIFY)  __________________________  

MAILING  ADDRESS:    _________________________________________________________________________  

GUARDIAN  INFORMATION    □      CHECK  IF  REQUESTING  PAPERWORK  FOR  SEPARATE  HOUSEHOLDS  

PRIMARY  GUARDIANS:  _____________________________________________PHONE:___________________  

EMAIL:  ____________________________________________________________________________________  

ADDRESS  (IF  DIFFERENT):  _____________________________________________________________________  

SECONDARY  GUARDIANS:  ___________________________________________  PHONE:__________________  

EMAIL:  ____________________________________________________________________________________  

ADDRESS  (IF  DIFFERENT):  _____________________________________________________________________  

EMERGENCY  CONTACTS  –  SOMEONE  OTHER  THAN  A  PARENT/GUARDIAN  WHICH  IS  REACHABLE  AT  A  DIFFERENT    
PHONE  NUMBER  THAN  THOSE  LISTED  ABOVE  AND  WHO  IS  ABLE  TO  PICK  UP  YOUR  CHILD  

1.        NAME:  ___________________________________  CONTACT  #:  _______________ALT  #:  ______________  

RELATIONSHIP  TO  SWIMMER  ________________________________      □  THIS  PERSON  HAS  A  SWIMMER,  TOO  

1.        NAME:  ___________________________________  CONTACT  #:  _______________ALT  #:  ______________  

RELATIONSHIP  TO  SWIMMER  ________________________________      □  THIS  PERSON  HAS  A  SWIMMER,  TOO  

1.        NAME:  ___________________________________  CONTACT  #:  _______________ALT  #:  ______________  

RELATIONSHIP  TO  SWIMMER  ________________________________      □  THIS  PERSON  HAS  A  SWIMMER,  TOO  

MEDIA  RELEASE  

WILLITS  OTTERS  SWIM  TEAM  HAS  MY  FULL  PERMISSION  TO  USE  MY  CHILD’S  NAME,  PHONE  REPRESENTATION,  
AND/OR  VIDEO  IMAGE  FOR  THE  PURPOSE  O  ACKNOWLEDGING  HIS/HER  ACHIEVEMENTS,  PROMOTING  TEAM  
EVENTS,  AND/OR  SHOWING  TEAM  MEMBERSHIP.  
   

  PLEASE  CHECK  THE  BOX  OF  ANY  FORMAT  THAT  YOU  DO  NOT  GIVE  PERMISSION  FOR:  
    □  NEWSPAPERS  □  WILLITS  OTTERS  WEBSITE     □  SWIM  MEET  PROGRAM  
    □  FLYERS     □  END  OF  SEASON  SLIDE  SHOW     □  TELEVISED  BROADCAST  

MEDICAL  INFORMATION:  

PHYSICAN:  _________________________________________________  PHONE:  ________________________  

DENTIST:  __________________________________________________  PHONE:  ________________________  

INSURANCE  PLAN:  ___________________________________________  ID#:  ___________________________  

IF  YOUR  CHILD  HAS  HAD  IN  THE  PAST,  OR  NOW  HAS  ANY  OF  THE  FOLLOWING  HEALTH  PROBLEMS  OR  CONDITIONS  
PLEASE  CHECK  AND  SPECIFY  BELOW:  

□  ASTHMA     □  BEE  STING  ALLERGY   □  EPILEPSY/CONVULSIONS     □  HIGH  FEVERS   □  HEART  CONDITION  

□  HYPO/HYPERGLEYCEMIA   □  LATEX  ALLERGY     □  MIGRAINES   □  FREQUENT  NOSE  BLEEDS   □  DIABETES  

□  FOOD  ALLERGY  (PLEASE  SPECIFY):  _________________________________________________________________  

□  MEDICINE  ALLERGY  (PLEASE  SPECIFY):  ______________________________________________________________  

□  MEDICATIONS  (PLEASE  SPECIFY):  __________________________________________________________________  

PERMISSION  TO  PARTICIPATE  AND  MEDICAL  RELEASE  

I,  the  undersigned,  do  hereby  give  my  full  permission  for  my  child  ____________________________________________________  
to  belong  to  the  Willits  ORers  Swim  Team  and  to  parUcipate  in  all  club  acUviUes.    I  understand  that  my  child  will  be  expected  to  
obey  all  club  rules  and  confine  his/her  acUviUes  to  those  areas  deemed  safe  by  the  coaching  staff.    I  also  understand  that  the  
Willits  ORers  Swim  Team  shall  not  be  liable  in  the  event  that  an  accident  should  occur  in  connecUon  with  the  club  acUviUes.    
Through  precauUons  will  be  taken  by  the  Willits  ORers  Swim  Team  to  provide  a  safe  experience.    I  further  understand  that  I  am  
responsible  for  the  safe  and  Umely  transportaUon  of  my  child  to  and  from  the  pool.  

I  further  authorize  the  representaUve  of  the  Willits  ORers  Swim  Team  to  authorize  the  afore  menUoned  child,  x/ray  examinaUon,  
anestheUc,  medical,  or  surgical  diagnosis,  or  treatment  and  hospital  care  which  is  deemed  advisable  by,  and  is  to  be  rendered  
under  the  general  or  special  supervision  of  any  licensed  physician  or  at  any  said  hospital.    It  is  understand  that  this  authorizaUon  is  
given  in  advance  of  any  specific  diagnosis,  treatment,  or  hospital  care  being  required.    This  authorizaUon  is  given  in  pursuant  to  
the  provision  of  SecUon  25.8  of  the  Civil  Cod  of  California.    In  addiUon,  I  do  hereby  waive,  release,  and  agree  to  hold  to  harmless  
the  Willits  ORers  Swim  Team,  the  organizers,  for  any  claim  arising  from  the  injury  except  to  the  extent  and  in  the  amount  covered  
by  accident  or  liability  insurance.  

GUARDIAN  SIGNATURE:  _________________________________________________  DATE:  ______________  

GUARDIAN  NAME:  _________________________________________________________________________