Registration Program

Registration Tryouts

Player Information

Player Full Name *

MM * 123456789101112

DD * 12345678910111213141516171819202122232425262728293031

YYYY * 2017

Gender * MaleFemale

Email *

Home Address *

Do you have any special requests? *

Parent/Guardian Information

Parent/Guardian 1 Name *

Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Email *

Parent/Guardian 2 Name *

Parent/Guardian 2 Cell Phone *

Parent/Guardian 2 Email *

Practice Sessions

Select One * 1 session Tryouts

Jersey Size

Select One * No Jersey

Marketing

How did you hear about us? * Ashland Stingrays SwimCoachCurrent Club MemberFacebookFriend or FamilyGoogleInstagramInternetMontclair moms!OnlineReturn PlayerSchool FlyerThe Montclairion MagazineWebsite

Emergency Contact Information

Primary Emergency Contact Person *

Relationship to Player *

Primary Emergency Contact Phone Number *

Secondary Emergency Contact Person (optional)

Relationship to Player (optional)

Secondary Emergency Contact Phone Number (optional)

Medical Information & History

Medical Insurance Company *

Medical Insurance Group Number *

Medical Insurance Policy Number *

Medical Insurance Phone Number *

Do you have any Allergies we need to be aware of? *

Yes

No

Please list your allergies *

Do you have medical conditions we need to be aware of? *

Yes

No

Please list any medical conditions we need to be aware of *

Please read and agree to the Club Policies & Waivers *

Yes

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SUBMIT

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