2019 20 swimrva rapids swim team registration · • use of any device with camera capabilities is...

2019/2020 SwimRVA Rapids Swim Team Registration LSC: Virginia Swimming

Last Name: ___________________________ First Name: _____________________________ Middle Initial: _____

Date of Birth: __________ Sex: ____ Age: ____ Mobile # ____________________ Mobile Carrier______________

Address: __________________________________________ City: _______________ State: _____ Zip: _________

Parent/Guardian 1: Last Name ____________________________ First Name ______________________________

Home # _________________ Mobile # ________________ Mobile Carrier ____________ Work # _____________

Email Address (Main Login) __________________________________________________

Parent/Guardian 2: Last Name ____________________________ First Name ______________________________

Home # ______________ Mobile # ________________ Mobile Carrier _______________ Work # _____________

Email Address __________________________________________________

Any medical conditions or allergies we should know about? _____________________________________________

Disability: Visually Impaired ____ Deaf/Hard of Hearing ____ Physical Disability ____ Cognitive Disability ___

Please explain: _________________________________________________________________________________

Ethnicity: Black/African American ____ Asian ____ White ____American Indian ____ Native Hawaiian ____

Hispanic/Latino ____ Other ________________________________________

Past Swimmer History: Swam on a year-round team before? Yes: ____ No: ____

Please give a brief description of past swimming history: ______________________________________________________

What Summer League Swim Team do you swim for? __________________________________________________________

T-Shirt Size(Y=Youth/A=Adult): Y-Sm ___ Y-Md___ Y-Lg___ A-Sm___ A-Md___ A-Lg___ A-XLg___

Swim Suit Size: Male___ Female ___ 22___ 24___ 26___ 28___ 30___ 32___ 34___ 36___ 38___

AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS/ELECTRIC FUNDS TRANSFER (EFT)

I (we) hereby authorize SwimRVA to charge/debit my account indicated below on the first of each month for payment of my monthly membership dues. This authority is to remain in full force and effect until SwimRVA has received written notification from me/us of its termination. If the payment is declined, I/we understand that SwimRVA, at its discretion, may attempt to process the charge again within thirty days, and may charge a $20.00 return fee for each returned payment. I also understand that I must notify SwimRVA by the 15th of the month before my requested cancellation date in order to stop the automatic draft.

Signature __________________________________________ Print ______________________________Date_________

Checking/Savings: Routing #: _____________________ Account #: ______________________ Bank Name: ____________

Credit/Debit card (select one): Visa MC Discover

CC #: ___________________________________________________ Exp. Date: ____/____ CVN: _______

NAME(S) (Please Print) ____________________________________________________________________

Emergency Contact: Last Name _________________________ First Name _________________________

Work # ____________________ Mobile # ____________________ Mobile Carrier______________

Email Address __________________________________________________

Insurance: Insurance Carrier/Company Name _____________________________________________________

Group Policy # _______________________________ Individual Policy # _______________________________

Primary Care Physician Name __________________________Phone Number ___________________________

I agree to participate in member directory? YES___ NO___

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Consent for Emergency Medical Attention:

In signing below, I consent to and authorize the performance of emergency medical care on all of my swimmers in the event that I am not available or cannot be reached. This medical service is to include whatever procedures are required to accomplish restoration of the structure and function of the disordered organ or organs. If any conditions are revealed at the time service is provided that were not recognized before and which call for emergency procedures in addition to those originally contemplated, I authorize and consent to the performances of such procedures. I also consent to and authorize the attending physician(s) or dentist(s) to prescribe any x-ray examination, anesthetic medical or surgical diagnosis or treatment, medication and hospital care that he/she (they) may consider advisable. I consent to and authorize the attending physician(s) to prescribe and administer the use of blood transfusions as he/she (they) may consider advisable. I agree to update any and all of the above information as necessary, especially prior to any team travel meet and to notify the SwimRVA office of any changes during the season. I assume financial responsibility for the cost of any and all emergency medical/dental expenses. I understand that this information will be shared on an as needed basis with SwimRVA coaches, staff, and trip chaperones. I understand that this consent for medical attention is revocable at any time but that without consent for medical attention, my child will not be permitted to participate in any team travel.

Signature __________________________________ Print ______________________________Date_________

Parent Agreement

Please read the following statements and initial next to each one of then indicating that you have read and fully understand them. If you have any questions, please direct them to the coaching staff.

_____ I have read, understand, and agree with the SwimRVA Rapids Electronic Communication and Bullying policies.

_____ As a member of the SwimRVA Rapids Swim Team, I promise to promote the sport of swimming, encourage teamwork and individual achievement while fostering sportsmanship and positive social interaction at all team events and online communication.

_____ I understand that I may not interrupt practice by giving instruction to my child or approaching coaches with questions, comments, concerns. If this becomes a problem, I will not be allowed on deck during practice.

_____ I will encourage my swimmer to approach his/her coach with question or concerns that may arise throughout the swim season.

_____ I understand that as soon as practice is over, I am responsible for my child and he/she is no longer under the supervision of the SwimRVA Rapids Swim Team coaching staff.

_____ I understand that I must have a credit card on file for my swimmers meet fees to be charged on the 1st of each month and swimmers monthly membership fees to be charged on the 1st of each month (if the credit card information changes I will inform the SwimRVA accounting department immediately)

Parent/Guardian Signature: ____________________________________________________ Date: __________

Swimmer Agreement

_____ As a member of the SwimRVA Rapdis Swim Team I promise to keep a positive attitude and show respect and good sportsmanship to my coaches, teammates and competitors.

_____ I have read, understand and agree with the SwimRVA Rapids Swim Team Electronic Communication and Bullying Policies, which can be found on the team’s website.

Swimmer Signature: ________________________________________________________ Date: ___________


WAIVER— PLEASE READ & SIGN

I hereby recognize and acknowledge that my or my child’s participation in recreational activities may involve bodily and/or emotional injury to myself and/or my child. In consideration of myself and my child being able to participate in such events, I, for myself, child (ren), heirs, executors and administrators, hereby voluntarily and knowingly indemnify and hold harmless, defend, release, waive, and discharge SwimRVA and its officers, employees and volunteers from any and all suits, claims or liability, including negligence. I therefore agree to pay for all medical, hospitalization or any other expenses resulting from my or my child’s participation. I hereby authorize SwimRVA staff to act on my behalf in accordance with their best judgment in case of an emergency involving me or my child (ren), and agree to assume full responsibility for all expenses, medical or otherwise, that may arise there from.

________________________________________________________________ ____________

Signature (Parent or guardian must sign if applicant is under 18 years old) Date

______I understand that the membership/pass fees are NOT REFUNDABLE, NOT TRANSFERABLE, AND NO EXTENSIONS WILL BE GRANTED. I and all others included in this membership/pass will obey all the rules and regulations set forth by SwimRVA. I understand failure to comply with these rules could result in suspension or revocation of this membership/pass.

SwimRVA Locker Room Rules

• Be Considerate Of Others.• Food, Gum, Beverages, And Glass Items are Prohibited in the Locker Room.• Use Of Any Device With Camera Capabilities Is Strictly Prohibited In The Locker Rooms. Failure To Follow This RuleCould Result In Suspension Or Termination Of Membership.• SwimRVA Prohibits Any Inappropriate Behavior. Please Report Any Such Behavior To A Staff Person.• Children 6 And Over Must Use Gender-Appropriate Locker Rooms. Please Follow All Posted Age Restrictions.• Secure All Items In A Locker With A Lock. SwimRVA Is Not Responsible For Lost Or Stolen Items.• Lockers Are For Day Use Only Unless Rented Through SwimRVA. Items Left In Lockers Overnight May Be RemovedAnd Donated To Charity.

If myself or my guests have family members who will need a family changing area, I understand that the facility has two small rooms separate from our main locker rooms for our convenience.

I understand that failure to comply with these rules could result in suspension or revocation of this membership/pass (without credit or refund).

________________________________________________________________ ____________


Photography Release

I hereby irrevocably consent to and authorize the use and reproduction by SwimRVA or anyone authorized by SwimRVA of any and all photographs and videos which might be or have been taken of me or my child during the program for any purpose whatsoever without compensation to me or my child for future promotional purposes.

________________________________________________________________ ____________


SwimRVA Rapids Bio SheetName: Age: School:

Previous Swim Team(s) & Experiences:__

What led you to deciding to join the Rapids?__

List your best/favorite events:____

List 2 or 3 events you want to learn about try or develop:__

Do you have an interest in swimming in college?__

What do you hope to achieve this short course/long course season?________

Favorite Type of Music:Favorite Type of Food:List Your Pets(s) or Favorite Animal:Favorite Sports Team(s):FFavorite Movie Ever and Favorite Recent Movie(s):List Any Siblings:One word to Describe Yourself:Favorite Hobby Other than Swimming:Favorite Subject in School:Your Special Talent:

Favorite Movie Ever and Favorite Recent Movie(s):List Any Siblings:One word to Describe Yourself:Favorite Hobby Other than Swimming:Favorite Subject in School:Your Special Talent:

Rapid Answer Round






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Favorite Type of Music:Favorite Type of Food:List Your Pets(s) or Favorite Animal:Favorite Sports Team(s):F

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What do you hope to achieve this short course/long course season?____

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Name: Age: School:



List your best/favorite events:__

Name: Age: School:




Name: Age: School:




Name: Age: School:




2019 20 swimrva rapids swim team registration · • use of any device with camera capabilities is...

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