EmailMe Form - Registration: Summer 2018 (May 1

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!

SUMMER WATER POLO PROGRAM:

Which Summer Program do you wish to register for? (please select only one) *

Summer Splashball (ages 5 and up) May and June only

U12 (players born 2007-2009) Deep Water

U14 (players born 2005 and 2006) Deep Water

U16/U18 (players born 2001-2004) Deep Water - REC players 2 practices only Tues & Thurs

I am unsure. Please contact me.

How many SUMMER practices per week will you be registering for (please select only one)? *

1 practice/week (Summer Splashball - Shallow Water) May and June only

2 practices/week (Deep Water)

3 practices/week (Deep Water)

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):

### - ### - ####

BCSSA Fee
(please select only one) *

Registering for Summer Splashball - $38.00

Registering for Summer Water Polo - $38.00

Registering for Summer Water Polo but BCSSA insurance purchased through another swim club.

Athletes registered with another BCSSA club:
Please provide the name of the BCSSA club you are registered with and your BCSSA registration number.

Please provide the name of the BCSSA club you are registered with and your BCSSA registration number.

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.