2022 Swim & Dive Team Registration "*" indicates required fields Date* MM slash DD slash YYYY Parent Name* First Last Parent Phone*Parent Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical Information & Release FormMother's Name* First Last Mother's Phone*Father's Name* First Last Father's Phone*Emergency Contact Name* First Last Emergency Contact Phone*Child's Physician's Name* First Last Child's Physician's Phone*Insurance Company and Policy Number* Allergies and/or Medical Conditions*Medications (list all)*Consent* I hereby grant consent to all health care providers to administer any necessary medical care as a result of injury/illness. This consent includes First Aid and transportation to/from health care providers. Child 1 InformationChild #1 Name* First Last Child #1 Gender*MaleFemaleChild #1 T-Shirt Size*Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeChild #1 Date of Birth* MM slash DD slash YYYY Child #1 Age as of June 1, 2022*345678910111213141516171819Child #1 Membership Status* Member Non-Member Is Child #1 a Lifeguard or Swim/Dive Coach?* Yes No Child #1 Registering For:* Lifeguard/Swim/Dive Coach - Swim & Dive Lifeguard/Swim/Dive Coach - Swim Only Lifeguard/Swim/Dive Coach - Dive Only Child #1 Registering For:* Swim & Dive Swim Only Dive Only Junior Dolphins - Swim & Dive Junior Dolphins - Swim Only Junior Dolphins - Dive Only Lifeguard/Swim/Dive Coach - Swim & Dive* Price: Lifeguard/Swim/Dive Coach - Swim & DiveLifeguard/Swim/Dive Coach - Swim Only* Price: Lifeguard/Swim/Dive Coach - Swim OnlyLifeguard/Swim/Dive Coach - Dive Only* Price: Lifeguard/Swim/Dive Coach - Dive OnlySwim & Dive* Price: Swim & DiveSwim & Dive* Price: Swim & DiveSwim Only* Price: Swim OnlySwim Only* Price: Swim OnlyDive Only* Price: Dive OnlyDive Only* Price: Dive OnlyJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyAdd a 2nd child?* Yes No Child 2 InformationChild #2 Name* First Last Child #2 Gender*MaleFemaleChild #2 T-Shirt Size*Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeChild #2 Date of Birth* MM slash DD slash YYYY Child #2 Age as of June 1, 2022*345678910111213141516171819Child #2 Membership Status* Member Non-Member Is Child #2 a Lifeguard or Swim/Dive Coach?* Yes No Child #2 Registering For:* Lifeguard/Swim/Dive Coach - Swim & Dive Lifeguard/Swim/Dive Coach - Swim Only Lifeguard/Swim/Dive Coach - Dive Only Child #2 Registering For:* Swim & Dive Swim Only Dive Only Junior Dolphins - Swim & Dive Junior Dolphins - Swim Only Junior Dolphins - Dive Only Lifeguard/Swim/Dive Coach - Swim & Dive* Price: Lifeguard/Swim/Dive Coach - Swim & DiveLifeguard/Swim/Dive Coach - Swim Only* Price: Lifeguard/Swim/Dive Coach - Swim OnlyLifeguard/Swim/Dive Coach - Dive Only* Price: Lifeguard/Swim/Dive Coach - Dive OnlySwim & Dive* Price: Swim & DiveSwim & Dive* Price: Swim & DiveSwim Only* Price: Swim OnlySwim Only* Price: Swim OnlyDive Only* Price: Dive OnlyDive Only* Price: Dive OnlyJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyAdd a 3rd child?* Yes No Child 3 InformationChild #3 Name* First Last Child #3 Gender*MaleFemaleChild #3 T-Shirt Size*Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeChild #3 Date of Birth* MM slash DD slash YYYY Child #3 Age as of June 1, 2022*345678910111213141516171819Child #3 Membership Status* Member Non-Member Is Child #3 a Lifeguard or Swim/Dive Coach?* Yes No Child #3 Registering For:* Lifeguard/Swim/Dive Coach - Swim & Dive Lifeguard/Swim/Dive Coach - Swim Only Lifeguard/Swim/Dive Coach - Dive Only Child #3 Registering For:* Swim & Dive Swim Only Dive Only Junior Dolphins - Swim & Dive Junior Dolphins - Swim Only Junior Dolphins - Dive Only Lifeguard/Swim/Dive Coach - Swim & Dive* Price: Lifeguard/Swim/Dive Coach - Swim & DiveLifeguard/Swim/Dive Coach - Swim Only* Price: Lifeguard/Swim/Dive Coach - Swim OnlyLifeguard/Swim/Dive Coach - Dive Only* Price: Lifeguard/Swim/Dive Coach - Dive OnlySwim & Dive* Price: Swim & DiveSwim & Dive* Price: Swim & DiveSwim Only* Price: Swim OnlySwim Only* Price: Swim OnlyDive Only* Price: Dive OnlyDive Only* Price: Dive OnlyJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyAdd a 4th child?* Yes No Child 4 InformationChild #4 Name* First Last Child #4 Gender*MaleFemaleChild #4 T-Shirt Size*Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeChild #4 Date of Birth* MM slash DD slash YYYY Child #4 Age as of June 1, 2022*345678910111213141516171819Child #4 Membership Status* Member Non-Member Is Child #4 a Lifeguard or Swim/Dive Coach?* Yes No Child #4 Registering For:* Lifeguard/Swim/Dive Coach - Swim & Dive Lifeguard/Swim/Dive Coach - Swim Only Lifeguard/Swim/Dive Coach - Dive Only Child #4 Registering For:* Swim & Dive Swim Only Dive Only Junior Dolphins - Swim & Dive Junior Dolphins - Swim Only Junior Dolphins - Dive Only Lifeguard/Swim/Dive Coach - Swim & Dive* Price: Lifeguard/Swim/Dive Coach - Swim & DiveLifeguard/Swim/Dive Coach - Swim Only* Price: Lifeguard/Swim/Dive Coach - Swim OnlyLifeguard/Swim/Dive Coach - Dive Only* Price: Lifeguard/Swim/Dive Coach - Dive OnlySwim & Dive* Price: Swim & DiveSwim & Dive* Price: Swim & DiveSwim Only* Price: Swim OnlySwim Only* Price: Swim OnlyDive Only* Price: Dive OnlyDive Only* Price: Dive OnlyJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyAdd a 5th child?* Yes No Child 5 InformationChild #5 Name* First Last Child #5 Gender*MaleFemaleChild #5 T-Shirt Size*Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeChild #5 Date of Birth* MM slash DD slash YYYY Child #5 Age as of June 1, 2022*345678910111213141516171819Child #5 Membership Status* Member Non-Member Is Child #5 a Lifeguard or Swim/Dive Coach?* Yes No Child #5 Registering For:* Lifeguard/Swim/Dive Coach - Swim & Dive Lifeguard/Swim/Dive Coach - Swim Only Lifeguard/Swim/Dive Coach - Dive Only Child #5 Registering For:* Swim & Dive Swim Only Dive Only Junior Dolphins - Swim & Dive Junior Dolphins - Swim Only Junior Dolphins - Dive Only Lifeguard/Swim/Dive Coach - Swim & Dive* Price: Lifeguard/Swim/Dive Coach - Swim & DiveLifeguard/Swim/Dive Coach - Swim Only* Price: Lifeguard/Swim/Dive Coach - Swim OnlyLifeguard/Swim/Dive Coach - Dive Only* Price: Lifeguard/Swim/Dive Coach - Dive OnlySwim & Dive* Price: Swim & DiveSwim & Dive* Price: Swim & DiveSwim Only* Price: Swim OnlySwim Only* Price: Swim OnlyDive Only* Price: Dive OnlyDive Only* Price: Dive OnlyJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim & Dive* Price: Junior Dolphins Swim & DiveJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Swim Only* Price: Junior Dolphins Swim OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyJunior Dolphins Dive Only* Price: Junior Dolphins Dive OnlyPayment InformationTotal Work Bond Amount: $50.00(To be paid separately as a check to Mark Elliott. Work bonds are returned to parents after you fulfill your work bond duties. If you do not fulfill them during the swim/dive season, they will be cashed). All Swim & Dive Registrations will be paid via Credit Card. Work Bonds will be paid by Check (which can be given to Mark Elliott).* Credit Card Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name Please remember all work bonds must be paid via check directly to Mark Elliott on top of paying for swim and/or registration fees via credit card or via check.CAPTCHA