FORMS ON PAGE:
New Swimmer Information Sheet - Returning Swimmer Information Sheet
Emergency Medical Release Form - Terms and Conditions for Participation
Northridge Area Swimming Association
NASA
(New) Swimmer Information Sheet
Swimmer Information:
Name: Last _______________First ____________Middle _____________
Preferred Name: ________________________ Gender: _______________
Age: ___________ Date of Birth: ________
School Attending Currently: _______________________ Grade: _______
Parents/Guardians Names: _______________________________________
Mailing Address: ______________________________________________
City: ___________________ Zip: ___________
Phone: ______________________ Emergency Phone: _______________
E-Mail Address:_______________________________________________
Some Informative Questions:
How did you find out about our club? _______________________________
Has your child had swimming lessons? YES NO Level Achieved: ______________________
Has your child had previous swim club experience? YES NO
What Club? ______________________Number of Years? _____________
Does your child have any siblings who are members of NASA? YES NO
Names: ______________________________________________________
What other activities/organized sports, if any, is your child involved in?
_____________________________________________________________
Are you interested in: SEASONAL DUES or INSTALLMENT PLAN
Northridge Area Swimming Association
NASA
Swimmer Information Sheet Training Group ______
Name: Last _______________ First _____________ Middle ____________
Preferred Name: __________________________ Gender: _____________
Age: ___________ Date of Birth: _________________
School Attending Currently: _______________________ Grade: ________
Parents/Guardians Names: _______________________________________
Mailing Address: ______________________________________________
City: ____________________ State: ___________ Zip: ______________
Phone: _____________________ Emergency Phone: _________________
E-Mail (Please print neatly!): _____________________________________
Northridge Area Swimming Association
Emergency Medical Release Form
SEPTEMBER 2008 – AUGUST 2009
Name of Swimmer______________________________________________________ Date:____________________
Parental Consent
This medical release form must be signed by a parent or legal guardian for EACH swimmer of the Northridge Area Swimming Association (NASA). If the swimmer is 18 years or older, the swimmer must also sign this form.
MEDICAL RELEASE
I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF,
_________________________________(name of swimmer) IS IN GOOD PHYSICAL CONDITION AND HAS NO CONDITION WHICH WOULD IMPAIR PARTICIPATION IN THIS PROGRAM. IN CASE OF INJURY, I HEREBY GIVE THE NORTHRIDGE AREA SWIMMING ASSOCIATION AND ITS COACHING STAFF OR MY CHILD’S CAREGIVER PERMISSION TO ACT ON MY BEHALF IN SEEKING MEDICAL TREATMENT FROM ANY LICENSED PHYSICIAN, HOSPITAL, OR CLINIC FOR MY CHILD IN THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY. I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO USING METHODS DEEMED NECESSARY. I ABSOLVE NORTHRIDGE AREA SWIMMING ASSOCIATION AND IT’S COACHING STAFF FROM ALL LIABILITY WHILE ACTING ON MY BEHALF IN THIS REGARD.
____________________________________ ____________________________________
Participant Signature (if over the age of 18) Parent/Guardian Signature
____________________________________ ____________________________________
Home Phone Number Parent Cell Phone or Work Phone
If parents are not available, please call the emergency contact designated below:
Name________________________________________ Phone Number____________________________
Address____________________________________________ __________________________________
Street City State ZIP
Additional information which may be needed in rendering medical treatment (medical history, allergies, drug reactions, medications, etc.):
______________________________________________________________________________________
______________________________________________________________________________________
__________________________________________ _____________________________________
Family Physician’s Name Physician’s Phone Number
Parent /Guardian Insurance Information (Please provide copy of your insurance card):
__________________________________________ _______________________________
Health Insurance Carrier Name of Policy Holder
__________________________________________ _______________________________
Policy/Group/Claim Number Phone Number
Terms and Conditions for Participation in the
Northridge Area Swim Association
(revised August 31, 2008)
Do you authorize NASA to include your swimmer in the team directory?
[ ] YES [ ] NO
I hereby give consent for my child(ren) to participate with NASA. In consideration of being permitted to participate as a member of NASA, I hereby release, discharge, and agree to hold harmless the Northridge Area Swim Association, and it’s coaches, members of the Board of Director’s, it’s volunteers, it’s agents and it’s employees, together with it’s successors and assigns, from any and all liability for injuries to property or person suffered as a result of participation as a member of the Northridge Area Swim Association. I give the club authorization to apply for USA Swimming memberships for my child(ren).
I agree to and will sign the following: “Terms and Conditions for Participation in the Northridge Area Swim Association Program” and the “Medical Release”. I have also read the NASA Handbook as well as the Behavior Policy, Board Rules, Meet/Volunteer Requirements and Practice Policy and agree to adhere to these rules.
SIGNED:______________________________________Date___________
Printed NAME:_______________________________________________
Swimmer’s name(s)___________________________________________