1. sports
2. polo

Santa Barbara 805 Water Polo Club
REGISTRATION PACKET
Dear Athletes & Parents,
Welcome! Enclosed are the following forms and instructions for enrolling in Water Polo
and/or Swimming.
1. Calendar & Payment Schedule
2. Registration Form
3. Release of Liability
4. Medical Release of Liability
5. Photo Release Form
6. Santa Barbara 805 Water Polo Club Code of Conduct
7. Join USA Water Polo (required). Register online at usawaterpolo.org.
-go to usawaterpolo.org
-click "join" in the top right corner
-new water polo members (10U/12U/14U/16U) and swim team members should sign
up for a "Silver" membership, OR a seasonal Red, White, or Blue membership.
-new SPLASHBALL members should sign up for a "Splashball" membership
(Our club name is "Santa Barbara 805") Club #26251
Please bring the completed packets and payment to practice.
Thank you. We hope you enjoy our programs.
Santa Barbara 805 Water Polo Club
805wpc.org
Santa Barbara 805 Water Polo Club
CALENDAR AND PAYMENT SCHEDULE
Fall Session:


September 1 - November 30
Payments are due on September 1
Winter Session:


December 1 - February 28
Payments are due on December 1
Spring Session:


March 1 - May 31
Payments are due on March 1
Summer Session:


June 1 - August 31
Payments are due on June 1
Dues (per session):

Splashball (ages 4-7) - $255.00

10 & Under Water Polo (ages 7-10) - $345.00

12 & Under through 18 & Under Water Polo - $495.00

Swim Team - $195.00

Masters - $150.00
Payment:


Credit Card: Online at 805wpc.org
Check: Payable to "SB 805 WPC"
Questions? Contact Cindy Hill ([email protected])
Santa Barbara 805 Water Polo Club
REGISTRATION FORM
Athlete First Name
Athlete Middle Initial
Athlete Last Name
Gender
Date of Birth
Grade
School
Male
Team (circle one)
10U
12U
Splashball
USA Water Polo # (required)
#_____________
Primary Email Address - for
billing and communication
Primary Cell Phone - for text
message communication
Father Name
Father Cell Phone
Father Email
Mother Name
Mother Cell Phone
Mother Email
Athlete Cell Phone
Athlete Email
If New, How did you hear
about our club?
Female
14U
16U
Swim Team
18U
Masters
expiration date:_________
Santa Barbara 805 Water Polo Club
WAIVER AND RELEASE OF ALL LIABILITY
In consideration of being allowed to participate in swimming, water polo, or any other aquatic program of Santa
Barbara 805 Water Polo Club (AKA “805 Water Polo Club” and/or “Santa Barbara Water Polo Club”), the undersigned
(hereinafter “Releasor”), as parent/guardian with legal responsibility for the participant, on behalf of myself, the
participant athlete, and all heirs, personal representatives, executors, administrators and assignees; hereby release,
waive, discharge, and agree to waive any and all claims, damages, and causes of action, and never to sue Santa
Barbara 805 Water Polo Club (AKA “805 Water Polo Club” and/or “Santa Barbara Water Polo Club”), their officers,
directors, agents, coaches, volunteers and/or employees, and, if applicable, the owners and/or lessors of any premises
used to conduct the lessons or any activities incidental thereto (hereinafter “Releasees”); with respect to any and all
injury, disability, death, loss or damage to person or property, whether arising from the negligence of the Releasees or
otherwise.
The risk of injury from the activities involved in this program is significant, including the potential for permanent INJURY
and DEATH, and while particular rules, equipment, and personal training may reduce such risk, the risk of serious
injury does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the
negligence of the Releasees or others, and assume full responsibility for my child’s participation. In order to help
reduce such risk, I agree to ensure that the participant complies with the stated and customary terms and conditions for
participation. If, however, I observe any unusual significant hazard during my presence, I will remove my child from
participation, and immediately bring such to the attention of the Santa Barbara 805 Water Polo Club (AKA “805 Water
Polo Club” and/or “Santa Barbara Water Polo Club”).
I agree to DEFEND, INDEMNIFY AND HOLD HARMLESS the Releasees from any and all claims, damages, suits,
liabilities, judgments, and costs, including attorney fees, arising out of, related to, and/or resulting from my child’s
participation in the swimming, water polo, or any other aquatic program of Releasors. I have freely and voluntarily
signed this release of liability and agree that it is binding upon me, my child, and all heirs, assigns and legal
representatives. I fully understand its terms, and understand that I have given up substantial rights, including the right
to sue, or otherwise make any claims as against Releasees, and intend by my signature below to provide a complete
and unconditional release of all liability to the greatest extent allowed by law.
THIS IS A RELEASE OF LIABILITY
DO NOT SIGN UNLESS YOU AGREE TO BE BOUND BY ITS TERMS
Parent/Guardian Name (printed): _______________________________________________________
Parent/Guardian Signature: ________________________________________ Date: _______________
Athlete Name(s):
Name: ____________________________________________
Name: ____________________________________________
Name: ____________________________________________
Santa Barbara 805 Water Polo Club
MEDICAL RELEASE AND AUTHORIZATION FOR TREATMENT
RELEASE
I hereby authorize any adult member accompanying the Santa Barbara 805 Water Polo Club (AKA “805 Water Polo Club” and/or “Santa
Barbara Water Polo Club”) team to consent to and authorize any medical or dental treatment that they, in their best judgment, determine
to be appropriate for my child,_______________________________________. I further authorize that the cost of such treatment be
submitted through the medical and dental plan(s) listed below.
ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
I further agree that I/we shall be responsible for any medical and dental charges incurred on behalf of my child, to the extent not paid by
the foregoing plan(s). I have read and understood all of the foregoing and agree/consent to same.
DATED (MONTH, DAY, YEAR)
FIRST PARENT/LEGAL GUARDIAN (SIGNATURE)
FIRST PARENT/LEGAL GUARDIAN (PRINT FULL NAME)
SECOND PARENT/LEGAL GUARDIAN (SIGNATURE)
SECOND PARENT/LEGAL GUARDIAN (PRINT FULL NAME)
MEDICAL
PLAN PROVIDER
GROUP NUMBER
POLICY NUMBER
DENTAL
PLAN PROVIDER
GROUP NUMBER
POLICY NUMBER
ALLERGIES, ADVERSE REACTIONS TO MEDICATIONS AND DIETARY RESTRICTIONS
ALLERGIES
ADVERSE REACTIONS TO MEDICATIONS DIETARY RESTRICTIONS
DIETARY RESTRICTIONS
Santa Barbara 805 Water Polo Club
PHOTOGRAPH RELEASE FOR ALL PARTICIPANTS
I hereby give my consent to the Santa Barbara 805 Water Polo Club (AKA “805 Water Polo Club” and/or “Santa
Barbara Water Polo Club”) to take and use photos of participants for publicity, advertising and web content
purposes. I hereby grant the Santa Barbara 805 Water Polo Club (AKA “805 Water Polo Club” and/or “Santa
Barbara Water Polo Club”) permission to use my/his/her likeness, name, voice and words in any broadcast,
telecast, print or electronic media of our events or activities free of charge. I release them from any expectation of
confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of
the children listed below.
Parent/Guardian: _______________________________________________________
Signature: ________________________________________ Date: ________________
Names and Ages of Minor Children:
Name: ____________________________________________Age: ________________
Name: ____________________________________________Age: ________________
Name: ____________________________________________Age: ________________
Name: ____________________________________________Age: ________________
Name: ____________________________________________Age: ________________
Name: ____________________________________________Age: ________________
Santa Barbara 805 Water Polo Club
ATHLETE’S AND PARENT/GUARDIAN’S CODE OF CONDUCT
Athlete’s Code of Conduct
In consideration of the rights granted to me by my selection to participate in Santa Barbara 805 Water Polo Club (AKA “805
Water Polo Club” and/or “Santa Barbara Water Polo Club”) activities, I consent to abide by the rules of conduct below. I
understand these rules apply to my behavior during all club activities at all locations. The Santa Barbara 805 Water Polo
Club (AKA “805 Water Polo Club” and/or “Santa Barbara Water Polo Club”) has a history of excellent behavior, and
therefore wish to underline the positive behavior of past athletes, and state our expectations of conduct.
I also understand that if I violate any of the following rules, I may be subject to whatever disciplinary action is deemed
appropriate by the coach and the club. The consequences for violating the rules on club sponsored activities will include:
1. Sitting out one or more meets, games, or practices.
2. Being sent home immediately from meets or games at personal expense for serious offenses or repeated
minor infractions.
3. Being terminated from membership in the program.
Inappropriate behavior will neither be condoned nor tolerated.
The following actions will be considered serious offenses in section one above:
1. Violation of any specific policies, regulations, or procedures of the club whether written or unwritten.
2. Inappropriate conduct as determined by customarily accepted behavior.
3. Physical, verbal, racial or sexual intimidation of any individual.
4. Disregarding instructions given by the coach or duly appointed guardians or chaperones.
5. Physical damage to a facility or theft of items from a room or from another person. (Restitution will be a required
part of any penalty imposed.)
6. Illegal transport, possession, or use of drugs, tobacco, or controlled substances.
7. Any action considered being an offense under federal, applicable state or local laws/ordinances.
All parents and guardians will discuss the club’s expectations and possible consequences with their son or
daughter before any trips.
Parent/Guardians’ Code of Conduct
In consideration of the rights granted to my child by their selection for participation in Santa Barbara 805 Water Polo Club
(AKA “805 Water Polo Club” and/or “Santa Barbara Water Polo Club”) activities, I consent to abide by the rules of conduct
below. I understand these rules apply to my behavior during all club activities at all locations. I understand if I violate any of
the following rules, my child or children are subject to whatever disciplinary action is deemed appropriate by the club. The
consequences for violating the rules include termination or suspension of membership of my child or children in the club,
limitations on me or my children’s participation in club activities or the filing or an appropriate judicial restraining order.
The following will be considered significant violations of the rules:
1. Violations of club policies, regulations, or procedures.
2. Criticizing or questioning coaching decisions with regard to practice or event participation.
3. Inappropriate conduct as determined by customarily accepted behavior.
4. Physical, verbal, racial, or sexual intimidation of any coach, athlete, official, or individual.
5. Harassing a coach or employee of the club while in the performance of their duties.
6. Failure to meet the financial obligations or make appropriate arrangements.
X___________________________________ X__________________________________
Printed Name of Athlete
Signature of Athlete
____/____/____
Date signed
X___________________________________ X__________________________________
Printed Name of Parent/Guardian
Signature of Parent/Guardian
____/____/____
Date signed
X___________________________________ X__________________________________
Printed Name of Parent/Guardian
Signature of Parent/Guardian
____/____/____
Date signed