Swimmer Registration Type

Stroke Clinic

SWIMMER #1

Full Legal Name
First
Middle
Last
Birthdate

Gender
---MaleFemale
Swim Experience
Level of swimming experience and any known interest/knowledge about the Nitros.

Swimmer Email (if available)

Swimmer Cell (if available)

SWIMMER #2

(If applicable)
Full Legal Name
First
Middle
Last
Birthdate

Gender
---MaleFemale
Swim Experience
Level of swimming experience and any known interest/knowledge about the Nitros.

Swimmer Email
(if available)

Swimmer Cell
(if available)

Do you wish to register more swimmers?
If yes, we will email for further details.
YesNo

FAMILY INFORMATION

Primary Parent Contact Name (required)

Cell (required)

Email (required)

Billing Contact (required)

Swimmer’s Home Address
Address (required)

City (required)

State (required)

Zip (required)

Billing Phone (required)

Free/Reduced Lunch Program (required)
May qualify for reduced USA Swimming registration fee. Requires verification from school.
YesNo

WAIVER & EMERGENCY INFO

SECONDARY/EMERGENCY CONTACT (if parent cannot be reached)
Name (required)

Phone (required)

Email

MEDICAL INFORMATION

IMPORTANT: THE PARENT/GUARDIAN IS RESPONSIBLE FOR NOTIFYING THE HEAD COACH OF ANY HEALTH CONCERN, INCLUDING THE SWIMMER’S USE OF MEDICATIONS, WHILE THE SWIMMER IS ACTIVELY PARTICIPATING ON THE SWIM TEAM.
Doctor Name (required)

Doctor Phone (required)

Medical Conditions
if multiple swimmers, please specify child name

Medications
if multiple swimmers, please specify child name

PRIVACY