Swimmer Name
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First Name
Last Name
Swimmer Birthdate
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Parent/Guardian #1
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First Name
Last Name
Parent/Guardian #1 Email
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Parent/Guardian #1 Phone Number
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Parent/Guradian #2 Name
First Name
Last Name
Parent/Guardian #2 Email
Parent/Guardian #2 Number
Mailing Address Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Check all that apply:
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Program Selection
Booster Committees
Please select a Booster Committee
Emergency Contact Name
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First Name
Last Name
Emergency Contact Relationship to Child
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Emergency Contact Phone Number
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Alternative Phone Number
Health Insurance: Policy Holder's Name
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Health Insurance Company Name
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Please note any medical conditions that we should be aware of (i.e.:food allergies, asthma)
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List all previous hospitalizations, if applicable.
If your swimmer has any mental or emotional needs which the staff should know about, please list them here:
Please list any medications your child is current taking, including over the counter.
Code of Conduct Check Box
1) I agree to conduct myselfcourteously, respectfully, and excellently.
2) I recognize the reputation of myself, my family, and the Ohio Coralinas Synchro Club are affected by and dependent upon my conduct and behavior at all times.
3) I will conform to all rules, regulations, and procedures announced by the Ohio Coralinas Synchro Club Coaches
4) I will not in any way endanger the safety of another swimmer.
5) I will compete in all my events to the best of my ability.
I understand and accept that failure to abide by the Ohio Coralinas Synchro Club Code of Ethics for Swimmers and Families may result in immediate disciplinary action, including but not limited to the following:
1) Suspension from the meet, event or practice.
2) Suspension or expulsion from the team.
3) Forfeiture of all payments or credits for participation in the meet or event.
4) Dismissal from the team. If the dismissal occurs while on a trip, the cost of the immediate return trip will be at the swimmer/parent's expense.
5) Should I conduct myself in such a way that brings discredit or discord to the Ohio Coralinas Synchro Club, I voluntarily subject myself to disciplinary action.
Release of Waiver and Liability
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AUTHORIZATION TO CONSENT TO PARTICIPATE IN OHIO CORALINAS SYNCHRO ACTIVITIES; CONSENT TO MEDICAL TREATMENT OF MINOR; LIMITATION OF LIABILITY; HEALTH STATEMENT. In consideration of being allowed to participate in any way in Ohio Coralinas Synchro Club (OCS) events, activities, or programs, I acknowledge and agree that:
1) I acknowledge that I am the parent and/or legal guardian of the aforementioned minor athlete, and have legal custody of said minor athlete.
2) I understand my minor child will be engaging in activities and travel that involve the risk of serious
injury, including permanent disability and death, severe social and economic losses, and other losses
including damage to property. I knowingly and freely assume all such risks.
3) I, individually, and/or on behalf of my minor child or ward, release, waive, discharge, and covenant not to sue Ohio Coralinas Synchro Club, its officers, agents, and employees, from any and all liability for any and all claims, demands, losses or damages on account of injury, including death and damage to property, whether caused by negligence or otherwise.
4) I, individually, and/or on behalf of my minor child, further hereby release OCS from any claim whatsoever which may arise as a result of any first aid treatment, services, or assistance provided in connection with any injury that arises from the activities of OCS.
5) I hereby give permission for emergency medical treatment to be administered as deemed appropriate. I agree that this release and waiver of liability is effective immediately. I expressly understand and agree the foregoing indemnity, release, and waiver are intended to be as broad and inclusive as permitted by the law of the State of Ohio and that any portion thereof is held invalid, it is agreed that the balance
shall, notwithstanding, continue in full force and effect.
6) I understand that the functions, activities, practice, and competition engaged in by Ohio Coralinas Synchro Club athletes, both aquatic and otherwise, include strenuous activity as a regular part of the Ohio Coralinas Synchro Club program. To the best of my knowledge, my minor athlete identified herein is in excellent physical and mental health and needs no restrictions from strenuous activity. If Ihave any questions regarding my child’s health, I understand that it is my obligation and responsibility
to seek professional medical advice and to inform the Ohio Coralinas Synchro Club of any health problems and/or restrictions on our child’s activities in writing.
7) I agree not to hold Ohio Coralinas Synchro Club, staff, board members, officers, volunteers, or agents responsible or liable in any way for accidents or injuries while volunteering at any practice, competition, or event at which the Ohio Coralinas Synchro Club is participating.
Media Consent Form
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We will be taking photos and videos of Ohio Coralinas Synchro Swimmers throughout the season for use on our website, publication on local newspapers, etc. We will only use photos of swimmers whose
parents give us permission to do so.
