Peace River Porpoises Swim Club 2015
Name of Swimmer
Date of Age as
Previous
Alberta health
medical
ASSA #
Allergies
Gender birth of April
Summer Club
care no.
history
(office use)
mm/dd/yy 30th
Winter Club
F / M
summer/winter/none
F / M
summer/winter/none
F / M
summer/winter/none
F / M
summer/winter/none
F / M
summer/winter/none
Mother's name:
Father's name:
Home phone:
cell phone:
Mailing address:
Work phone:
Other contact name:
Contact
phone:
E mail address:
Family Doctor:
Registration
fee
Cost $
Number of
swimmers
Total
Paid
$ / Cheque
Fundraising Fees: 3 cheques of $100 each
$100 postdated for June15,2015 (bottle drive on May 24,15, Tickets for
dinner at senior's center date TBD in June)
beginners
$ 250 X
=
$100 postdated for June 30,15 (swim-a-thon June 10,2015)
$100 postdated for July 25,15 (raffle tickets))
Junior
$ 300 X
=
Cheques are only cashed if you are unable to meet the participation
Intermediate
$ 385 X
=
Advance
$ 385 X
=
Total:
requirements for an activity listed above. Meeting participation
requirements for an activity will result in your cheque being returned.
Yes No
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Consent form
I Consent to having my swimmer’s name published on the ASSA website, swim meet results, and Peace River Porpoises website.
I hereby acknowledge receipt of a copy of the Peace River Porpoises Swim Club Parent Handbook for the
summer swim season and certify that the above named swimmer(s) has my permission to take part in the
activities supervised and controlled by the coach(es). I hereby release the organization, its members and
2
exe-
cutive as well as the coach(es) of any and all responsibility for any accident or injuries resulting from his/her
participation in this program. In the event of an emergency, such as a sudden illness or accident and the parent/
guardian cannot be reached by telephone, the coach (or designate) has my permission to take my child to our
family doctor, or another available doctor.
Fundraising: I understand that I have to pay 3 x $100 by postdated cheques for participation in 3 of 4 fundraisers
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(bottle drive, dinner at senior's center, swim a thon and raffle tickets) and that I have the opportunity
to have one cheque returned for each activity that I meet the participation requirements.
If you decide to withdraw from swimming at the end of the trial period (1 week) it is your responsibility to contact the
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registrar, Carole Skolseg at 780-624-1546, email: [email protected] to ensure your registration money is not cashed.
My children are allowed to use the hot tub at the Peace Regional Pool.
Date:__________________Signature:______________________________ Print Name____________________________