Blue/Gold Group Registration Form

Welcome to the 2011-2012 Coast Guard Blue Dolphins Swim Team. Please fill out this form for each swimmer you are registering with the team. If you have more than one swimmer, you must fill out a seperate form for each child. This form will serve as your registration form and your permission for emergency care. YOU MUST PRINT THE CONFIRMATION E-MAIL, SIGN IT, AND MAIL BACK TO THE OFFICE (CGBD, 607 Lotz Dr, Yorktown, VA 23692). Please print the e-mail using your print function and don't send a screen shot. It is very difficult to read the small print from a screen shot.

ALL SWIMMERS MUST PARTICIPATE IN A TRYOUT PRIOR TO REGISTERING FOR BLUE/GOLD GROUP. IF YOU NEED TO SCHEDULE A TRYOUT PLEASE DO SO BY CALLING THE TEAM OFFICE AT 757-369-2202.

If you have any questions about the team or the form(s) please contact the office at 757-369-2202 or cgbdteamadmin@cox.net

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Swimmer's Information

Swimmer's Legal Name (Last)

Swimmer's Legal Name: (First)

Swimmer's Legal Name: (Middle)

Swimmer's Preferred Name: (If Different)

Date of Birth: (mm/dd/yyyy)

Gender

Select Swimmer's Group

Select Location

Swimmer's Cell Phone:

Enter a valid phone number. Example: 123-456-7890

Swimmer's Email:

Enter a valid email address. Example: name@company.com

Swimmer's School:

Parent's Information

Parent/Guardian Names:

Street Address:

City:

State:

Zip Code:

Primary Contact E-mail:

Enter a valid email address. Example: name@company.com

Home Phone:

Enter a valid phone number. Example: 123-456-7890

Dad's Work Phone:

Dad's Work E-mail:

Dad's Cell Phone:

Mom's Work Phone:

Mom's Work E-mail:

Mom's Cell Phone:

Medical/Insurance Information

Family Physician:

Physician Phone Number:

Enter a valid phone number. Example: 123-456-7890

Emergency Contact (Other than parents):

Emergency Contact Number:

Enter a valid phone number. Example: 123-456-7890

Insurance Company Name and Billing Address:

Policy Number/ ID Number:

In case of emergency, when my family physician or I may not be reached, the Coast Guard Blue Dolphins Swim Team (duly authorized coach or chaperone) has my permission to provide treatment which a physician deems necessary.

I agree that my electronic signature below is binding

Parent Signature:

Date