Year-round Competitive Swimming
SAN JUAN SWIM CLUB- STINGRAYS
REGISTRATION & MEDICAL INFORMATION
I. NAME: _____________________________________ dob: _____________
FIRST MI LAST
ADDRESS: _____________________________________________________zip_____ PARENTS’ NAMES: _________________________________________________
HOME PH_____________________ EMERGENCY # ________________
II. Provide HOME EMAIL ADDRESS: _____________________________
III.MEDICAL INFORMATION:
1. Is your child allergic to any food or medications? ___Y ___N
If yes, please list: ____________________________________
2. Is your child taking any medication on a continuous basis? ___Y ___N
If yes, please list: _____________________________________
3. Has your child been treated for (circle all that apply)?
Asthma Diabetes Seizures or Epilepsy
Heart Disease Kidney or Liver Disease Lung Disease
4. Has your child had any of the following in the last 2 years (circle)?
Head Injury Fracture
5. Does your child wear contact lenses or a dental appliance? ___Y ___N
Please list any medical condition we should be aware of that could affect your child’s practice or performance… ____________________________________________________________
“These questions have been answered truthfully to the best of my knowledge. My son/daughter does not have any medical conditions that would adversely affect his/her personal safety while in or around the water. To the best of my knowledge, my child is healthy enough to participate in a rigorous, aerobic-based, competitive SWIMMING, WATERPOLO AND/OR DIVING program.”
III. EMERGENCY MEDICAL AUTHORIZATION:
“I hereby grant permission for any duly authorized doctor, paramedic, emergency medical technician, hospital or other medical facility, in case of injury, to treat said minor(s) while he/she/they is(are) a participant(s) or observer(s) at any event sanctioned or approved by USA SWIMMING/US WATERPOLO OR USA DIVING.
Parent/Guardian Signature: ________________________ Date ___/___/___
