EmailMe Form - Winter 2017 Water Polo Registration: ADULTS Only

SURREY ORCA'S WATER POLO CLUB

EmailMeForm

ATHLETE INFORMATION:
Athlete's Name: *
First Last
Athlete's Email Address:
Athlete's Primary Contact Number
Athlete's Secondary Contact Number
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!
EMERGENCY CONTACT:
Emergency Contact Name: *
First Last
Emergency Contact Phone (Cell):
### - ### - ####
Please ensure this is a valid phone number.
Emergency Contact Phone (Home):
### - ### - ####
Please ensure this is a valid phone number.
Registration, Insurance & Permissions
REGISTRATION: I wish to participate in the 1 practice per week adult program (select one) *
Yes, Adult Program, registering for the season
Yes, Adult Program, paying a weekly drop-in fee
BCSSA - Membership/Insurance Fee *
Yes, Adult Program
BCWP Insurance Fee: Adult - $25 (annual)
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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Surrey Orca's Water Polo Club | Located in the Guildford Aquatics Centre, Surrey, B.C.

ATHLETE INFORMATION:

EMERGENCY CONTACT:

Registration, Insurance & Permissions