Temp – Swim and Dive Payment Form – Ben Franklin Swim Club

2022 Swim & Dive Team Registration

"*" indicates required fields

Date*

Parent Name*

First Last

Parent Phone*

Parent Email*

Address*

Street Address Address Line 2 City State ZIP Code

Medical Information & Release Form

Mother'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 Information

Child #1 Name*

First Last

Child #1 Gender*

Child #1 T-Shirt Size*

Child #1 Date of Birth*

Child #1 Age as of June 1, 2022*

Child #1 Membership Status*

Member

Non-Member

Is Child #1 a Lifeguard or Swim/Dive Coach?*

Yes

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 & Dive

Lifeguard/Swim/Dive Coach - Swim Only*

Price:

Lifeguard/Swim/Dive Coach - Swim Only

Lifeguard/Swim/Dive Coach - Dive Only*

Price:

Lifeguard/Swim/Dive Coach - Dive Only

Swim & Dive*

Price:

Swim & Dive

Swim & Dive*

Price:

Swim & Dive

Swim Only*

Price:

Swim Only

Swim Only*

Price:

Swim Only

Dive Only*

Price:

Dive Only

Dive Only*

Price:

Dive Only

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Discount*

Price:

Discount

Add a 2nd child?*

Yes

Child 2 Information

Child #2 Name*

First Last

Child #2 Gender*

Child #2 T-Shirt Size*

Child #2 Date of Birth*

Child #2 Age as of June 1, 2022*

Child #2 Membership Status*

Member

Non-Member

Is Child #2 a Lifeguard or Swim/Dive Coach?*

Yes

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 & Dive

Lifeguard/Swim/Dive Coach - Swim Only*

Price:

Lifeguard/Swim/Dive Coach - Swim Only

Lifeguard/Swim/Dive Coach - Dive Only*

Price:

Lifeguard/Swim/Dive Coach - Dive Only

Swim & Dive*

Price:

Swim & Dive

Swim & Dive*

Price:

Swim & Dive

Swim Only*

Price:

Swim Only

Swim Only*

Price:

Swim Only

Dive Only*

Price:

Dive Only

Dive Only*

Price:

Dive Only

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Add a 3rd child?*

Yes

Child 3 Information

Child #3 Name*

First Last

Child #3 Gender*

Child #3 T-Shirt Size*

Child #3 Date of Birth*

Child #3 Age as of June 1, 2022*

Child #3 Membership Status*

Member

Non-Member

Is Child #3 a Lifeguard or Swim/Dive Coach?*

Yes

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 & Dive

Lifeguard/Swim/Dive Coach - Swim Only*

Price:

Lifeguard/Swim/Dive Coach - Swim Only

Lifeguard/Swim/Dive Coach - Dive Only*

Price:

Lifeguard/Swim/Dive Coach - Dive Only

Swim & Dive*

Price:

Swim & Dive

Swim & Dive*

Price:

Swim & Dive

Swim Only*

Price:

Swim Only

Swim Only*

Price:

Swim Only

Dive Only*

Price:

Dive Only

Dive Only*

Price:

Dive Only

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Add a 4th child?*

Yes

Child 4 Information

Child #4 Name*

First Last

Child #4 Gender*

Child #4 T-Shirt Size*

Child #4 Date of Birth*

Child #4 Age as of June 1, 2022*

Child #4 Membership Status*

Member

Non-Member

Is Child #4 a Lifeguard or Swim/Dive Coach?*

Yes

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 & Dive

Lifeguard/Swim/Dive Coach - Swim Only*

Price:

Lifeguard/Swim/Dive Coach - Swim Only

Lifeguard/Swim/Dive Coach - Dive Only*

Price:

Lifeguard/Swim/Dive Coach - Dive Only

Swim & Dive*

Price:

Swim & Dive

Swim & Dive*

Price:

Swim & Dive

Swim Only*

Price:

Swim Only

Swim Only*

Price:

Swim Only

Dive Only*

Price:

Dive Only

Dive Only*

Price:

Dive Only

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Add a 5th child?*

Yes

Child 5 Information

Child #5 Name*

First Last

Child #5 Gender*

Child #5 T-Shirt Size*

Child #5 Date of Birth*

Child #5 Age as of June 1, 2022*

Child #5 Membership Status*

Member

Non-Member

Is Child #5 a Lifeguard or Swim/Dive Coach?*

Yes

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 & Dive

Lifeguard/Swim/Dive Coach - Swim Only*

Price:

Lifeguard/Swim/Dive Coach - Swim Only

Lifeguard/Swim/Dive Coach - Dive Only*

Price:

Lifeguard/Swim/Dive Coach - Dive Only

Swim & Dive*

Price:

Swim & Dive

Swim & Dive*

Price:

Swim & Dive

Swim Only*

Price:

Swim Only

Swim Only*

Price:

Swim Only

Dive Only*

Price:

Dive Only

Dive Only*

Price:

Dive Only

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim & Dive*

Price:

Junior Dolphins Swim & Dive

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Swim Only*

Price:

Junior Dolphins Swim Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Junior Dolphins Dive Only*

Price:

Junior Dolphins Dive Only

Payment Information

Total

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 Express

Discover

MasterCard

Visa

Card Number

Expiration Date

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.

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2022 Swim & Dive Team Registration

Medical Information & Release Form

Child 1 Information

Child 2 Information

Child 3 Information

Child 4 Information

Child 5 Information

Payment Information

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