Clinton Hills Swim Club | Water Polo Clinics sign up

2020 Water Polo Registration Form

Water Polo Clinics

CHSC is pleased to annouce two, 3-day water polo clinics!

Keira Hassel, our CHSC waterpolo coach, will offer two WP clinics:

08/03-8/5
08/10-8/12

Keira will instruct participants in skills and techniques necessary for successful waterpolo play. (Ages 12-18 unless approved by Coach Keira.)

Limiting participation to 9 swimmers for appropriate social distancing and safety.

$15 for one week-long clinic, made up of three 45 minute sessions, 8:30pm to 9:15pm, M/T/W.

Parent-Guardian Name*

First Last

Parent-Guardian Address*

Street Address Address Line 2 City State ZIP Code

Parent-Guardian Phone*

Parent-Guardian Phone 2

Parent-Guardian Email*

Parent-Guardian Email 2

Clinic Participant Details

Participants

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Emergency Medical Info

Emergency Contact

Emergency Contact - Relationship to Swimmer

Emergency Contact Phone

Physician's Name

Physician's Phone

Dentist's Name

Dentist's Phone

Medical History

Please list any facts concerning your child's medical history, including allergies, medications, and any relevant problems to which a physician should be alerted.

Medical Waiver*

In the event that reasonable attempts to reach me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above named doctor or dentist, or in the event the designated preferred practitioner is not available, by another physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not include major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

I agree to the Medical Waiver

Medical Liability*

I hereby agree that the Clinton Hills Swim Club, its coaches, members, and board shall not be liable for any injury or loss that my child or children may sustain while participating in activities of any kind whether sponsored by or under the supervision of Clinton Hills Swim Club. I agree to indemnify and hold harmless Clinton Hills Swim Club and its members, coaches, and board or designates of any kind from any claim whatsoever.

I agree to the Medical Liability

Full Name*

Please type your full name to acknowledge and accept all aspects of this e-form.

Signature*

Registration Fee:

$15/session plus 7% Sales Tax.

Clinic Fees*

Price: $0.00

$15/Session + tax ($16.05/ session)

Total

$0.00

Credit Card*

American Express

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MasterCard

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Card Number Expiration Date Security Code Cardholder Name

Phone

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