EmailMe Form - Registration: Spring 2017 (May/June)

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!
SPRING WATER POLO PROGRAM: MAY/JUNE
Which SPRING (May/June) program do you wish to register for? (please select only one) *
Splashball! (Introductory) (10U) (Shallow Water)
12U (players born 2005, 2006 and 2007) (Deep Water)
14U (players born 2003 and 2004) (Deep Water)
16U (players born 2001 and 2002) (Deep Water)
18U (players born 1999 and 2000) (Deep Water)
I am unsure. Please contact me.
How many SPRING practices per week will you be registering for (please select only one)? *
1 practice/week (Splashball Program Only) (Shallow Water)
2 practices/week (Deep Water)
3 practices/week (Deep Water)
4 practices/week (Deep Water)
I am unsure. Please contact me.
Which SPRING practice days will your athlete be attending (please indicate the days your athlete is registered for)?
1 practice/week (Splashball Program Only) (Shallow Water)
Monday
Tuesday
Wednesday
Thursday
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):
### - ### - ####
BCWP Insurance Fee
(please select only one) *
No fee due. I was registered in the 2016/17 season.
Yes, I need to pay. I was not registered in the 2016/17 season.
I'm not sure, please contact me.
BCWP insurance fee is required if not already insured for the 2016/17 season (contact the registrar for details if you are not certain).
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 and that my full name may be used. 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:

SPRING WATER POLO PROGRAM: MAY/JUNE

PRIMARY AND SECONDARY PARENT/GUARDIAN INFORMATION: