VERGENNES CHAMPS SWIM TEAM

REGISTRATION / MEDICAL/PHOTO RELEASE FORM

vergennesswimteam@gmail.com

Swimmers Information

Last Name:_______________________________________________ First Name:________________________________________

D.O.B._____/_____/______ Age:______ Sex:______ Phone:_________________________________________________________

Address:________________________________________ City/Town/ Zip:______________________________________________

Email:_____________________________________________________________________________________________________

Email:_____________________________________________________________________________________________________

Medical History: Check only those that apply. Do you currently have or have you had in the past?

_____broken bones _____sprains / torn ligaments _____seizure / epilepsy_____ wear glasses / contacts _____concussion

_____spinal injury_____ asthma: medication: ____________________________________________________________________

_____allergies-type________________medication:________________________________________________________________

_____other conditions / injuries: _______________________________________________________________________________

Insurance and Emergency Information:

Name of Policy Holder: _____________________________ Phone #:__________________________________________

Insurance Company: _______________________________ Policy #:__________________________________________

Physician: ________________________________________ Phone #:__________________________________________

Hospital Preference: _________________________________________________________________________________________

1. Name of Parent/Guardian: ______________________________ Cell Phone #:___________________________________

Address: _____________________________________________Home Phone #:_________________________________

2. Second Contact Person: ________________________________Cell Phone #:___________________________________

Relationship to Athlete: _________________________________Home Phone #:_________________________________

I give my permission for my son/daughter to participate in the sport of swimming during the 2017 Vergennes summer swim team
season. I understand there are inherent dangers associated with any sport, and agree to hold harmless, without liability, the Vergennes
Swim Team in its entirety including the Coaches, the Board, the Champlain Valley Swim League and VSA. I give permission for the
Vergennes Swim Team coaching staff to seek emergency medical treatment for my child(ren) if deemed necessary.
By signing below, I hereby grant permission to publish photographs in the local print media (newspaper, website, facebook,bulletin
board) of my child. This only applies to these sites as associated with Vergennes Swim Team. We have no control over any other
postings as they may occur in social media.

Parent / Guardian Signature: _______________________________________________Date:_______________________________

Please make checks for swimmer fee payable to City of Vergennes