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TRI-M CYO SWIM TEAM

2016/2017
SWIMMING PROGRAM FOR BOYS

NAME OF SWIMMER

DIVISION

PRESENT AGE

DATE of BIRTH

PARENTS NAME

SCHOOL
PARISH

ADDRESS

GRADE

CITY & ZIP

MEDICAL INFO
(Asthma,allergies,etc.)

HOME PHONE

CELL PHONE mother


father

E-MAIL ADDRESS
PRINT CLEARLY

I hereby give my child________________________________________permission to participate in the TRI-M CYO swim program. I authorize a coach, trained lifeguard
or adult representative of the team to provide emergency treatment of an injury or illness to my child. This authorization is granted only if I cannot be
reached and a reasonable effort has been made to do so.
Parent or Guardian's Signature______________________________________________
I understand that this team/program operates solely on the swim fees paid by the participants. All personnel are volunteers except for the lifeguards.
I hereby agree to volunteer my time for locker room duty as the program needs me.
Parent or Guardian's Signature______________________________________________
If you have any questions, please call Mary Leong 718-793-4082

TEAM______

CLUB________
FOR OFFICE USE ONLY
PAID__________________

CHECK# OR CASH____________

HS_______

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