Hummelstown Swim Team

2011 Summer Season

Registration Form

 

The registration fee for 2011 is $75.00 per child.  Checks should be made payable to the Hummelstown Swim Club.  Please complete a registration form for EACH swimmer and mail to Coach Cari Zelko, 221 Fox Grove Place, Hummelstown, PA 17036 with the required registration fee(s).

 

Swimmer & Family Information

 

Name (Last, First): ________________________________________Birth date: ____________  Age as of 6/1/11  _____                      

 

Gender (M/F):               Shirt Size:                 Shoe Size: _______                                      

 

Primary Contact (Parent’s Names): ____________________________________________________________________                                                                                                                                           

Address: _________________________________________________________________________________________

 

Home Phone:                                                   Work Phone:                                             Cell Phone:__________________

 

Email address:_____________________________________________________________________________________

 

List Secondary Contact (if different from Primary Contact):_________________________________________________

 

_________________________________________________________________________________________________

Family Physician:                                                                                      Phone Number:___________________________

 

Emergency Contact:                                                                                  Phone Number: __________________________ 

Indicate any special information and/or medical conditions:_________________________________________________

 

Winter Swimmer (yes/no)                     If yes, where:______________________________________________________

School District of Swimmer:___________________________________________________________________________________

Are you able to obtain the newsletter and information from the webpage www.hstswimming.org?  Circle one:   Yes     No

 

Permission Statement and Waiver of Liability

 

This is to confirm that the above-named swimmer has my permission to participate in the 2011 Summer Hummelstown Swim Team (HST) program.  It is understood that HST and HSC do not provide hospitalization and medical insurance and are not legally responsible for any injury or death to a participant in the HST/HSC program.

 

Please check the appropriate information below:

 

The above-named child is covered under our family hospitalization and medical insurance.

 

 We have no hospitalization or medical insurance to cover our child.  Therefore, in the absence of family insurance coverage, the parent/guardian will assume the responsibility in case of injury or death.  I, hereby, relieve the HST and its coaches and HSC and its personnel from responsibilities in case injury or death should occur.

 

I give my permission for the above-named child to be treated in my absence for any emergency.

 

Further, I hereby waiver any claim for bodily injury, death, or property damage against the Hummelstown Swim Club and its personnel and Hummelstown Swim Team and its coaches while the above-named swimmer is a participant on the Hummelstown Swim Team.

 

Parent/Guardian Signature:                                                                                                           Date: ________________         

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