EmailMe Form - Registration: Winter 2017

ATHLETE INFORMATION:
Athlete's Name: *
First Last
Athlete's Email Address:
Enter an email address ONLY IF DIFFERENT than primary or secondary parent address – this email address belongs to the athlete.
Athlete's Address: *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Athlete's Date of Birth: *
MM / DD / YYYY
Gender: *
Male
Female
Athlete's Medical Card Number: *
No spaces between the numbers please!
RECREATIONAL LMWPL PROGRAM REGISTRATION:
Which Recreational LMWPL program do you wish to participate in? (please select only one) *
Splash! (Introductory Water Polo)
10U Flippers! (Introductory Advanced)
12U (players born 2005, 2006, 2007) (Deep Water)
14U (players born 2003, 2004) (Deep Water)
16U (players born 2001, 2002) (Deep Water)
18U (players born 1999, 2000) (Deep Water)
Adult
ALL GIRLS Guest (must belong to a water polo club)
BCPL or NCL Prep Guest (must belong to a water polo club)
I am unsure. Please contact me.
If you selected ALL GIRLS Guest, BCPL or NCL Prep Guest above, please name the water polo club you play with:
How many practices per week will you be registering for? *
1 practice/week (Splash!, Adult, ALL Girls Guest, BCPL or NCL Prep Guest only)
2 practices/week
3 practices/week (includes ALL Girls, BCPL or NCL Prep practice and SOWPC Members)
4 practices/week (includes BCPL or NCL Prep practice and SOWPC Members)
I am unsure. Please contact me.
Are you interested in participating in our competitive programs (coach assessment required):
Yes
No
I am unsure. Please contact me
PRIMARY AND SECONDARY PARENT/GUARDIAN INFORMATION:
Please enter the Primary Parent/Guardian contact information:
Primary Parent Name: *
First Last
Primary Parent Email: *
Primary Parent Phone (Cell):
### - ### - ####
Please ensure this is a valid phone number.
Primary Parent Phone (Home):
### - ### - ####
Please ensure this is a valid phone number.
Secondary Parent Name:
First Last
Secondary Parent Email:
Enter Secondary parent email only if DIFFERENT than primary parent email.
Secondary Parent Phone (Cell):
### - ### - ####
Secondary Parent Phone (Home):
### - ### - ####
MEMBERSHIP AGREEMENTS
BCWP or BCSSA - Membership/Insurance Fee
(please select only one) *
Registering for Splash or Flippers (BCWP $30 for one session or $60 annually)
Registering for 12U, 14U, 16U or 18U (BCWP $60 annual plus BCSSA $25 as required)
Registering for Adults (BCWP $25)
BC Provincial League (BCWP $50 additional)
Volunteer Fee *
N/A if registering for Splash, Adult or ALL Girls and BCPL/NCL Only Prep (one session)
I agree to include a volunteer cheque for $100 (applicable to all programs EXCEPT Splash, Adult or ALL Girls and BCPL/NCL Only Prep (one session)
NOTE, full credit will be refunded if 100 Volunteer Points total during season (see Policy for details).
Opt-Out of Volunteering?
Place Check mark here if you wish to opt out of Volunteering and have your $100 cheque cashed now.
Fundraising Fee *
N/A if registering for Splash, Adult or ALL Girls and BCPL/NCL Only Prep (one session)
I agree to include a fundraising cheque for $100 (applicable to all programs EXCEPT Splash, Adult or ALL Girls and BCPL/NCL Only Prep (one session)
NOTE: Full credit will be refunded if fundraising requirement is met during season (see Policy for details).
Opt-Out of Fundraising?
Place Check mark here if you wish to opt out of Fundraising and have your $100 cheque cashed now.
Agreement to Play *
Yes, I give my agreement to play water polo with the Surrey Orcas Water Polo Club.
Agreement to Play
I apply to play water polo with the Surrey Orcas Water Polo Club. I understand that the player is responsible for observing the rules of the club at all times. I agree to participate at my own risk. I agree to travel to games at my own risk. I understand that a mouth guard is recommended for all games.
Media and Sharing of Information Permission *
Yes, I give my permission
No, I do not give my permission
I give permission for the use of any photographs and/or videos take for media coverage or promotions. I give permission for my name and contact information to be shared with the Team Manager for communications purposes.

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ATHLETE INFORMATION:

RECREATIONAL LMWPL PROGRAM REGISTRATION:

PRIMARY AND SECONDARY PARENT/GUARDIAN INFORMATION:

MEMBERSHIP AGREEMENTS