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609-896-0683 (Seasonal*)99 Lewisville Road, Lawrenceville, NJ 08648
Ben Franklin Swim Club
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2022 Swim & Dive Team Registration

"*" indicates required fields

MM slash DD slash YYYY
Parent Name*
Address*

Medical Information & Release Form

Mother's Name*
Father's Name*
Emergency Contact Name*
Child's Physician's Name*
Consent*

Child 1 Information

Child #1 Name*
MM slash DD slash YYYY
Child #1 Membership Status*
Is Child #1 a Lifeguard or Swim/Dive Coach?*
Child #1 Registering For:*
Child #1 Registering For:*
Lifeguard/Swim/Dive Coach - Swim & Dive
Lifeguard/Swim/Dive Coach - Swim Only
Lifeguard/Swim/Dive Coach - Dive Only
Swim & Dive
Swim & Dive
Swim Only
Swim Only
Dive Only
Dive Only
Junior Dolphins Swim & Dive
Junior Dolphins Swim & Dive
Junior Dolphins Swim Only
Junior Dolphins Swim Only
Junior Dolphins Dive Only
Junior Dolphins Dive Only
Add a 2nd child?*

Child 2 Information

Child #2 Name*
MM slash DD slash YYYY
Child #2 Membership Status*
Is Child #2 a Lifeguard or Swim/Dive Coach?*
Child #2 Registering For:*
Child #2 Registering For:*
Lifeguard/Swim/Dive Coach - Swim & Dive
Lifeguard/Swim/Dive Coach - Swim Only
Lifeguard/Swim/Dive Coach - Dive Only
Swim & Dive
Swim & Dive
Swim Only
Swim Only
Dive Only
Dive Only
Junior Dolphins Swim & Dive
Junior Dolphins Swim & Dive
Junior Dolphins Swim Only
Junior Dolphins Swim Only
Junior Dolphins Dive Only
Junior Dolphins Dive Only
Add a 3rd child?*

Child 3 Information

Child #3 Name*
MM slash DD slash YYYY
Child #3 Membership Status*
Is Child #3 a Lifeguard or Swim/Dive Coach?*
Child #3 Registering For:*
Child #3 Registering For:*
Lifeguard/Swim/Dive Coach - Swim & Dive
Lifeguard/Swim/Dive Coach - Swim Only
Lifeguard/Swim/Dive Coach - Dive Only
Swim & Dive
Swim & Dive
Swim Only
Swim Only
Dive Only
Dive Only
Junior Dolphins Swim & Dive
Junior Dolphins Swim & Dive
Junior Dolphins Swim Only
Junior Dolphins Swim Only
Junior Dolphins Dive Only
Junior Dolphins Dive Only
Add a 4th child?*

Child 4 Information

Child #4 Name*
MM slash DD slash YYYY
Child #4 Membership Status*
Is Child #4 a Lifeguard or Swim/Dive Coach?*
Child #4 Registering For:*
Child #4 Registering For:*
Lifeguard/Swim/Dive Coach - Swim & Dive
Lifeguard/Swim/Dive Coach - Swim Only
Lifeguard/Swim/Dive Coach - Dive Only
Swim & Dive
Swim & Dive
Swim Only
Swim Only
Dive Only
Dive Only
Junior Dolphins Swim & Dive
Junior Dolphins Swim & Dive
Junior Dolphins Swim Only
Junior Dolphins Swim Only
Junior Dolphins Dive Only
Junior Dolphins Dive Only
Add a 5th child?*

Child 5 Information

Child #5 Name*
MM slash DD slash YYYY
Child #5 Membership Status*
Is Child #5 a Lifeguard or Swim/Dive Coach?*
Child #5 Registering For:*
Child #5 Registering For:*
Lifeguard/Swim/Dive Coach - Swim & Dive
Lifeguard/Swim/Dive Coach - Swim Only
Lifeguard/Swim/Dive Coach - Dive Only
Swim & Dive
Swim & Dive
Swim Only
Swim Only
Dive Only
Dive Only
Junior Dolphins Swim & Dive
Junior Dolphins Swim & Dive
Junior Dolphins Swim Only
Junior Dolphins Swim Only
Junior Dolphins Dive Only
Junior Dolphins Dive Only

Payment Information




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*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 



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.

Club Location:
99 Lewisville Rd Lawrenceville, NJ 08648

Mailing Address:
P.O. Box 6371 Lawrenceville, NJ 08648

Info: info@benfranklinswimclub.com

Phone:  609-896-0683 (Seasonal*)

* Seasonal phone is only available during hours of operation

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