2023 Registration

Participant's Information

Name*

First Middle Initial Last

Nickname

Birth Date*

Age on 6/1/2022 (in years)*

Gender*

Age Group as of June 1*

Year just completed in school*

This will be my child's (blank) year on this swim team.*

Mother/Guardian Full Name*

Father/Guardian Full Name*

Child lives with*

If other, please describe*

Primary Contact Information

Mail to Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Do you need to list Secondary Contact information (if other parent/guardian?)*

No
Yes, my child has contact info at another address in addition to the primary address

Secondary Contact Information

Mail to Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email

Agreement to Terms

Photo Permission*

Yes, photos of my child may be used.
No, photos of my child may not be used.

I give the Waterloo Piranhas Swim Team permission to use images taken of my child at any time while participating in Waterloo Piranhas Swim Team activities. I understand that these pictures may be used in team advertising, marketing and for promotional purposes of the team.

Permission*

Yes, I agree

My child has permission to participate in the Waterloo Piranhas Swim Team. I will not hold the Piranhas Parents Club, the coaches, or the pool owners responsible for any injuries my child may incur while participating in Piranhas practices, meets, or activities. I understand that disrespect of any kind shown toward any coach, adult supervisor, team member, or any opposing team will not be tolerated. I further understand that such behavior will result in my child's immediate dismissal from the Piranhas Swim Team.

By typing your name here and submitting this form, you are consenting to these terms.*

Emergency Medical Consent Statement

Child's Name*

I, the undersigned parent/guardian of (child's name), do hereby consent to have prompt, definitive emergency medical care administered to the aforementioned minor child in my absence. In doing so, I release the administering facility and/or individual from responsibility for medical services performed. The Waterloo Piranhas Swim Team and/or its coaches, representatives, officers, and members are hereby absolved of any responsibility for injuries incurred during Piranhas practices, meets, or activities.

By typing your name here and submitting this form, you are consenting to these Emergency Medical terms.*

Known Allergies, please list and describe below*

Medications (prescription and nonprescription, including supplements / vitamins):*

My child is presently under the care of a physician*

Yes
No

Please list the condition(s) your child is being treated for:

My child is*

Diabetic
Asthmatic
None of these

(check all that apply)

Emergency Contact Name*

Emergency Contact Relationship to Child*

Emergency Contact Phone*

Family Physician*

Insurance Plan Provider*

Insurance Plan ID Number*

How did you hear about the Waterloo Piranhas Swim Team?

How would you like to pay?*

Online through PayPal
Check / Cash (Cash - hand directly to a Board Member. Check - see below mailing address)

Waterloo Piranhas Swim Team
Attn: Micki Hansel
8618 Fernwood Dr
Columbia, IL 62236

NOTE: When paying by Cash or Check, there is no 3.49% Processing Fees
First Swimmer = $90.00
Second Swimmer = $67.50
Third + Swimmer = $45.00

STOP!!
Click the orange SUBMIT button. THEN, if paying online, scroll down to choose BUY NOW to pay.

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Swim Team Registration – 2023 Season

Part 1: Fill Out Registration Form

Swim Team Registration 2022

Participant's Information

Primary Contact Information

Secondary Contact Information

Agreement to Terms

Emergency Medical Consent Statement

Part 2: PayPal Payment for this Registration