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SIGN UP
DEADLINE:
MAY 11TH
COMPETITIVE STROKE CLINIC
MAY 12TH - JUNE 4TH 2015
Participants MUST be able to complete one length of the pool (25 yards) freestyle, without stopping or
using the side of the pool. Stroke clinic is not a swimming lesson. Participants who are unable to meet
this requirement will be removed from the clinic.
CLINIC TIMES
CLINIC FEES
GROUP 1
GROUP 2
Ages 6- 10
Tuesday & Thursday
5-5:45 PM
Ages 11 & UP
Tuesday & Thursday
6-6:45 PM
SWIMMERS FULL NAME
SEX (M/F)
Five Points Members:
1st Swimmer $50
Each Additional Swimmer $40
Non Members:
1st Swimmer $60
Each Additional Swimmer $50
AGE
GROUP 1
GROUP 2
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Checks payable to: Five Points Washington
Total Enclosed__$_______________
Address: __________________________________________________________________________________
City: ________________________________________________________ Zip code: _____________________
Email address: ____________________________________________ Phone: ___________________________
Mother: _____________________________________ Father: _______________________________________
Emergency Contact Information
Emergency Contact: _________________________________ Relationship: ____________________________
Phone (home/work &/or cell): (H)_________________(W)_________________(Cell):____________________
PLEASE READ CAREFULLY AND SIGN:
________________________________ HAS MY PERMISSION TO PARTICIPATE IN THE FIVE POINTS WASHINGTON SWIMMING PROGRAM. IN THE EVENT
THAT I CANNOT BE REACHED DURING AN EMERGENCY, I(WE) THE UNDERSIGNED GIVE PERMISSION FOR MY CHILD TO BE TREATED BY A LICENSED
PHYSICIAN, AND FOR SAID PHYSICIAN TO ADMINISTER WHATEVER CARE IS NECESSARY, INCLUDING ANESTHESIA FOR THEIR SAFETY AND CARE. THE
CHILD’S FAMILY WILL BE RESPONSIBLE FOR ALL OF THE ASSOCIATED MEDICAL EXPENSES. ALSO I(WE) WAIVE AND RELEASE ANY RIGHT AND CLAIMS I
(WE) MAY HAVE AGAINST FIVE POINTS WASHINGTON, AND ALL MEMBERS OF FIVE POINTS BOARD FOR ANY AND ALL DAMAGES WHICH MAY BE
SUFFERED BY MY CHILD IN CONNECTION WITH HIS/HER ASSOCIATION WITH THE SWIMMING PROGRAM.
I also understand that pictures may be taken for promotional consideration and may be used in future publications and advertisements.
SIGNATURE OF PARENT_______________________________________________DATE_____________