P O Box 552, Hopkins, MN 55343
Last Name |
Legal First Name |
Middle Name |
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Preferred Name |
Date of Birth |
Age |
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Sex |
Home phone |
Other phone (specify) |
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Swimmer Mailing Address |
City |
Zip |
Parent email address |
Swimmer email
address (optional) |
School Attending |
Current Grade |
How did you learn of Club? |
Father’s Name |
Daytime Phone |
Mother’s Name |
Daytime Phone |
Disability: Blind or Visually Impaired__________ Deaf or hard of hearing _______ Physical disability such as amputation, cerebral
palsy, dwarfism, spinal injury, mobility impairment___________ Cognitive
disability such as autism, mental retardation, learning disorder___________________________________
Ethnicity: African-American________ Asian or Pacific Islander__________ Caucasian_____________
Hispanic_________ Native American_______________ Other_________________ Decline info_______
Doctor/Clinic Name |
Phone number |
Preferred Hospital |
ASSUMPTION OF LIABILITY – WAIVER OF CLAIM: I recognize that a swimming pool and its surroundings are an inherently dangerous/hazardous environment and that participating with the Swim Club exposes my child to constant risk. I AGREE TO BE RESPONSIBLE FOR THE ACTIONS OF MY CHILD DURING PARTICIPATION IN ALL CLUB ACTIVITIES. I hereby waive all claims against the Swim Club, its officers, board members and coaches from any harm, injury or accident incurred by my child as a result of my child’s participation in the Hopkins Swim Club.
In case of accident or serious illness, I request that the coach contact me. If unable to reach me, I hereby authorize him/her to contact the doctor listed above and follow their instructions. If it is impossible to contact this doctor, or if, in the coach’s opinion there is an emergency, I authorize the coach to make whatever arrangements seem necessary, including calling 911.
Parent/Guardian Signature______________________________________ Date_____________________
By signing above, parents and swimmers agree to abide by the Hopkins Swim Club Code of Conduct.