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Highbridge
Aquatics Registration
In order
for me to complete USS cards when the time comes, please make
sure to list the complete name. I must have middle names.
If you prefer to be listed as something other than your formal
name, please list nicknames. In addition to the registration
form, every Highbridge Aquatics swimmer must have a Medical
Release Form on file.
Mail to: Chris Fugmann, 10 Olde Village
Drive, Nicholasville, KY 40356-8714
Name_______________________________________________
_______________________________________________
_______________________________________________
Address_____________________________________________
City___________________________
Zip_________________
Home Phone
__________________________
Cell Phone
____________________________
E-Mail
address ____________________________________
____________________________________
Emergency
Phone Numbers or Contacts: __________________________________
__________________________________
Birthdates(s):
__________________ __________________ __________________
Parent(s)
First Name: ____________________ ____________________
Please
list any medical concerns the coaching staff should be aware
of.
AGREEMENT
As parent
of legal guardian of the children named above, I hereby give
my full consent and approval for my children to participate
in USA swimming activities and competition as member of the
Highbridge Aquatics team. I understand that there are certain
risks of injury inherent in the practice and play of this
sport, as well as in traveling and other related activities
incidental to my children's participation, and am willing
to assume those risks on behalf of my children. I do here
waive, release, and hold harmless the Highbridge Aquatics,
its directors, officers, coaches, employees and representatives
for any injury that may be suffered by my children in the
course of participation in USA Swimming activities incidental
thereto. I hereby certify that my child is fully capable of
participating in USA Swimming and that my child is healthy
and has no physical or mental disabilities or infirmities
that would restrict full participation in these activities.
I have read and fully understand the provisions contained
in this agreement.
Printed
Name of Parent/Guardian ________________________________________________
Signature
___________________________________________________________________
Date _____________________________
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