Registration and Swimmer Information. (Please Print)

Transcription

1 Kona Dolphin Swim Club PO Box 695 Kailua Kona, HI Registration and Swimmer Information (Please Print) Full Name of Swimmer: Date of Birth: Nickname: Sibling in Club:_ Full Name(s) of Parent(s) or Guardian(s): Mailing Address: Telephone Number(s): _ Home:_ Work: For: Work: For: Cell: For: Cell: For: (primary):_ (other): Medical Information: Family Physician: Tel. No. Insurance Provider:_ Pol. No. Preferred Hospital or Medical Facility: Any medical conditions, allergies or medication requirements of which the Kona Dolphin Swim Club should be aware of: (If None, please write none ) School:_ Grade: Organized Swimming Experience (other clubs, camps, or instruction programs- names & locations):_

2 SWIM GROUPS We have three groups (Spinner Dolphins, Spotted Dolphins and Racer Dolphins) that swim on different days and at different hours. This schedule is designed so that all of our swimmers will receive the attention and coaching they need to progress to higher levels. Coach Harry has placed each swimmer in a specific group. He will move a swimmer up into a more advanced group when he thinks that swimmer is ready. To be eligible to move up to the next group, a swimmer must have a good attendance record for six months and be able to finish the whole practice session. Please remember which days and at what times your child is scheduled to swim. Please be punctual and always bring your swimsuit, goggles, cap and towel! PARENTS OBLIGATIONS TO PAY DUES AND FEES family) Spinner and Spotted Dolphins: Racer Dolphins: Annual U.S. Swimming Registration: Semi-annual Administration Fee: $67.50 (paid monthly) $77.91 (paid monthly) $67.00 (paid yearly) $20.00 (paid when you join & every 6 months thereafter per Payment is due on the first of each month. Payment must be received and posted before midnight on the 14th of each month. Late fees will be assessed by the system at 12:01 A.M. on the 15th of each month. A late fee charge of $10 will be imposed on dues received after that date. Check your account balance and/or set up auto payments using a credit/debit card or bank account at If paying by check please make your check payable to KONA DOLPHINS SWIM CLUB.. The Annual U.S.A Swimming Registration and Semi-Annual Administration Fee as well as your first month of dues are to be paid when you first sign up. AGREEMENT We (I) have read and understand the information set forth above concerning the mission and objectives of the Kona Dolphins Swim Team and the respective responsibilities of parents, swimmers and the Team. We (I) understand that if our (my) child needs to be taken to an emergency facility, he or she will be taken to the nearest appropriate one. We (I) give my consent to the Kona Dolphins Swim Club staff to take appropriate action for the safety and welfare of our (my) child. We (I) wish to have our (my) child become a member of the Club and agree that we (I) are (am) responsible to pay the dues and fees set forth above in a timely manner and to make every effort to have our (my) child comply with the rules of the Team and the direction of the Coaches so long as he or she remains a member. Signed: (Print Name:_) Dated:, 20 Signed: (Print Name:_)

3 UNITED STATES SWIMMING, INC. LIABILITY / MEDICAL RELEASE FORM Required liability / medical release form to be furnished by non-u.s. Swimming, Inc. member participating in a covered competition. Instructions: All forms should be given to the athlete with sufficient time for him/her to read and digest its contests before signing, especially if the parent/guardian signature is needed as well. If I am injured while participating at Kona Dolphin Swim Club / Kona Community Aquatic Center, (1) I and my family agree to waive any legal claim against United States Swimming (USS), and those associated with USS, Hawaiian Swimming and Kona Dolphin Swim Club; (2) I give consent for Kona Dolphin Swim Club to provide medical/athletic training attentions, transportation and emergency medical services as warranted. If the program in which I am participating includes Physiological and/or Biomechanical evaluations, I further consent to these evaluations which pose no unusual risks or hazards when customary safeguards are observed. If injured while traveling to or from Kona Dolphin Swim Club activities by public, private or any other means of conveyance, I agree to waive any legal claims against USS, Hawaiian Swimming and Kona Dolphin Swim Club. By signing this release, I swear that I am in good physical condition and I am not aware of any disease or injury that would result in my being injured during any program participation. If I am less than 18 years of age or a minor under the laws of the state where I live, my parent or guardian shall sign this release for me. I agree that I will not bring or possess alcoholic beverages, illegal drugs or International Olympic Committeebanned substances on the premises. I further understand and agree to abide by general rules of conduct prescribed for participants in this function and that violations may result in denial of meet privileges. Signature Printed Name Date Signature of Parent/Guardian Date Street Address City, State, Zip Phone Number (s)

4 Kona Dolphin Swim Club PO Box 695 Kailua Kona, HI CHECKLIST Registration/ Rates/ Member Information Sheet(s) USA Swimming Liability/ Medical Release Form Copy of Birth Certificate USA Swimming Athlete Registration Application (s) Registration fee for USA Swimming $67.00 (per child) $_ Monthly Club Fee Spotted or Spinner Dolphins $67.50 (per child) $_ Racer Dolphins $77.91 (per child) Semi-annual administration Fee $20.00 (per child) $_ TOTAL $_

5 USA SWIMMING 2015 ATHLETE REGISTRATION APPLICATION LSC: HAWAIIAN SWIMMING PLEASE PRINT LEGIBLY COMPLETE ALL INFORMATION: LAST NAME LEGAL FIRST NAME MIDDLE NAME PREFERRED NAME DATE OF BIRTH (MO/DAY/YR) SEX (M/F) AGE CLUB CODE NAME OF CLUB YOU REPRESENT (Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter Unattached FATHER/GUARDIAN LAST NAME FATHER/GUARDIAN FIRST NAME MOTHER/GUARDIAN LAST NAME MOTHER/GUARDIAN FIRST NAME FINA MAILING ADDRESS U.S. CITIZEN: YES NO CITY STATE ZIP CODE ARE YOU A MEMBER OF ANOTHER FEDERATION? YES NO AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD ADDRESS IF YES, WHICH FEDERATION: HAVE YOU REPRESENTED THAT MAKE CHECK PAYABLE TO: DISABILITY: RACE AND ETHNICITY (You may FEDERATION AT INTERNATIONAL A. Legally Blind or Visually Impaired check up to two choices): Athletes to Your Local Club. COMPETITION? YES NO B. Deaf or Hard of Hearing Q. Black or African American C. Physical Disability such as R. Asian amputation, cerebral palsy, S. White Clubs CLUBS MAIL to Hawaiian APPLICATION Swimming & PAYMENT TOf: dwarfism, spinal injury, T. Hispanic or Latino HAWAIIAN SWIMMING 2015 REGISTRATION mobility impairment U. American Indian & Alaska Native D. Cognitive Disability such as V. Some Other Race FEE severe learning disorder, W. Native Hawaiian & Other Pacific c/o Gwenn Tomiyoshi autism Islander Sept. 1, 2014 through Dec. 31, 2015 HIGH SCHOOL STUDENTS Year of high school graduation: 171 G. Ainaola Dr Check if you USA would Swimming like to learn more Fee about the $52.00 USA YEAR LAST REGISTERED:. IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2014, ENTER THAT Swimming Foundation s initiatives Hilo, HI Check if you LSC would like Fee to receive the electronic USA CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB:. Swimming Newsletter (must be 13 years of age or older) SIGN $15.00 HERE x _ SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE TOTAL ONLY DUE _ $67.00