Chesapeake Swim Club New Member Online Packet

CHESAPEAKE SWIM CLUB REGISTRATION FORM Updated 1/7/13SWIMMER REGISTRATION (please print) Last Name First Name (Legal) M.I. M/F Birth Date mm/dd/yy Age Start Date Swimmer’s preferred name __________________________________________________________________ Parent's Name__________________________________________________________________________________ Last Name Father Mother Address: _____________________________________________________________________________________ Street/PO Box City Zip Code Phone: _______________________________________________________________________________________ Home Work-­‐Father Work-­‐Mother Cell-­‐Father Cell-­‐Mother Please circle the two best numbers to use to reach you. E-­‐mail Address: ________________________________________________________________________________ Primary {used for website username for login} Secondary Monthly Dues: starting from the 1 st through the 15 th – pay full month’s dues; starting from the 16 th to the end of the month, pay 50% of the monthly dues. Red _____________ @ $65.00 =_____________ Blue _____________ @ $75.00 =_____________ Silver _____________ @ $85.00 =_____________ Gold _____________ @ $92.00 =_____________ Sr. Dev. _____________ @ $102.00 =_____________ Senior ___________ @ $117.00 =_____________ Sectional__________ @ $127.00 =_____________ National __________ @ $132.00 =_____________ Meets Only________ @ $57.00 =_____________ Total monthly dues _______________ Annual USA Swimming Registration (2013) _____ @ $54.00 = _____________ Total Amount Due: _____________ HOME POOL: (circle one) OCCC OCUSA LIGHTHOUSE Please read and initial: * I understand the fee structure and the policy regarding refunds. _______ * I understand 30 days written notice will be given to the administrator when withdrawing from the team. _______ * I understand my monthly payment must be made by the due date to avoid a $25.00 late fee. _______ * I understand the policies regarding volunteering. ________ * I give my permission for the individuals named above to participate in CSC activities, unless I notify the club in advance and in writing. ________ * I certify that the above answers are correct and that the individuals (s) named above are eligible in accordance with the rules of USA Swimming. ________ Signature of Parent/Guardian: ____________________________________________ Date: ____________*********************************Office use only************************************ _____ CSC Registration Form _____ Medical Exam & Report ______ Photo Release _____ Dues _____ Authorization/Consent ______ USA Swimming Registration Form _____ DOB proof _____ Service Hour Agreement _____ E-­‐mail _____ Code of Conduct ______ Transfer Form 7