2012 Online Swim Team Registration Form


Lakeside Hurricanes

2012 Swim Team Registration Form

PLEASE REMEMBER –

EVERY FAMILY MUST VOLUNTEER

AT ALL SWIM MEETS


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Number of Swimmers
You must complete the following information so we can register your child(ren) for the swim team.
________________________________________________________________________________
Information about Parent #1
First Name
Last Name
Email
Address
City, State, Zip
Primary Phone
Secondary Phone
Additional Phone
Emergency Contact Name
Emergency Contact Phone #
________________________________________________________________________________
Information about Parent #2. (If applicable.)
First/Last Name
Email
Address (if different)
City, State, Zip (if different)
Phone Number
Secondary Phone
___________________________________________________________
Information about Swimmer 1
Last Name
First Name
Middle Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Swimmer 2
Last Name
First Name
Middle Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Swimmer 3
Last Name
First Name
Middle Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Swimmer 4
Last Name
First Name
Middle Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Swimmer 5
Last Name
First Name
Middle Name
Date of Birth (dd/mm/yyyy)
________________________________________________________________________________
Terms of Registration and Release of Liability:
● LSRC (Lakeside Swim and Racquet Club) requires all families to provide volunteers at every swim meet.
● LSRC hosts a variety of fundraising events and activities throughout the season. All families are strongly encouraged to participate.
● LSRC Swimmers, Coaches, Parents/Guardians must maintain an ethical Code of Conduct when attending any function given by or related to LSRC.
● As the parent or legal guardian of the child(ren) named above, member(s) of LSRC, I acknowledge that my child(ren) will participate in practices, swim meets and other team events.
● If my child(ren) require(s) medical attention, I hereby give LSRC, its coaching staff or designee, permission to authorize medical treatment including but not limited to emergency room treatment.
● I hereby release Lakeside Swim and Racquet Club, its coaching staff or designee from all claims that may arise out of the exercise of this authority.
________________________________________________________________________________
Payment Information:
● I understand that the amount owed for registration to the Lakeside Hurricanes Swim Team must accompany this registration form.
● I understand that my child(ren) will not be able to practice with the team until my LSRC Membership Dues are paid for the 2012 season.
● Access to the facility will not be granted until full payment has been received.
● Payments can be made in the form of a check (payable to LSRC) or via credit card. There will be a service fee applied to all credit card transactions and a $30 charge for all returned checks.
________________________________________________________________________________
Please contact Kim Barnes at golsrc@yahoo.com regarding any questions or concerns.
You will be directed to the online payment screen when you submit this application. You may pay online, or exit the payment screen and mail your payment to LSRC, P.O. Box 9614, Richmond, VA 23228 Be sure to include the membership name with your payment.

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