2012 - 2013 registration form parent or guardian information primary contact:...
TRANSCRIPT
2012 - 2013 Registration Form
Parent or Guardian InformationPrimary Contact: __________________________________________________
Address: _________________________________________________________
City: _______________________ Zip Code: ____________________________
Home Phone: ______________________Email________________________
Cell Phone: ___________________________
Emergency Contact: _______________________________________________
Emergency Contact Phone#: _________________________________________
BIRTH CERTIFICATES ARE REQUIRED FOR ALL SWIMMERS!
Various Fees
1. Team Registration – One time fee per family $30.00
2. AZ/USA Swimming Fee – For Season and per Swimmer $61.00
3. Monthly Training Fees**- Fees are due for Each Swimmer at the Beginning of Each Month.
A) Olympic Way (OW) $65.00 Mon-Thur. 4pm-5pm (2 days a wk)
B) Bronze $75.00 Mon-Thur. 4pm-5pm (3 days)
C) Silver $85.00 Mon-Thur: 5pm-6:30pm, Fri: 4pm-5:30pm
D) Gold $95.00 Mon-Thur: 5pm-7pm, Fri: 4pm-5:30pm
**$10.00 Discount will be applied for 2nd, 3rd, and 4th, Children of a Family.
SWIMMER INFORMATIONSwimmer 1
Last Name: ___________________ First Name: _______________ Initial: ____
Preferred Name: ______________________
Birth Date: ______/______/_______ Age: ________ Grade: ________
School: __________________________________________________________
LIST BELOW ALL MEDICAL CONDITIONS AND MEDICATIONS…(Please print clearly)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
In the event of a medical emergency and if we’re unable to contact you, the parent or guardian, that you, the parent or guardian, does authorize the SunWest Swimming Team Coach in attendance to provide medical assistance, treatment, and/or transportation to the nearby medical facility for my child.
Signature of Parent or Guardian: ____________________________________
Print Name of Parent or Guardian: __________________________________
My signature above is proof that I consent to the participation of the above athlete in the Club Swim program.
SWIMMER INFORMATIONSwimmer 2
Last Name: ___________________ First Name: _______________ Initial: ____
Preferred Name: ______________________
Birth Date: ______/______/_______ Age: ________ Grade: ________
School: __________________________________________________________
LIST BELOW ALL MEDICAL CONDITIONS AND MEDICATIONS…(Please print clearly)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
In the event of a medical emergency and if we’re unable to contact you, the parent or guardian, that you, the parent or guardian, does authorize the SunWest Swimming Team Coach in attendance to provide medical assistance, treatment, and/or transportation to the nearby medical facility for my child.
Signature of Parent or Guardian: ____________________________________
Print Name of Parent or Guardian: __________________________________
My signature above is proof that I consent to the participation of the above athlete in the Club Swim program.
SWIMMER INFORMATIONSwimmer 3
Last Name: ___________________ First Name: _______________ Initial: ____
Preferred Name: ______________________
Birth Date: ______/______/_______ Age: ________ Grade: ________
School: __________________________________________________________
LIST BELOW ALL MEDICAL CONDITIONS AND MEDICATIONS…(Please print clearly)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
In the event of a medical emergency and if we’re unable to contact you, the parent or guardian, that you, the parent or guardian, does authorize the SunWest Swimming Team Coach in attendance to provide medical assistance, treatment, and/or transportation to the nearby medical facility for my child.
Signature of Parent or Guardian: ____________________________________
Print Name of Parent or Guardian: __________________________________
My signature above is proof that I consent to the participation of the above athlete in the Club Swim program.
PAYMENTSwimmer Information
Swimmer 1
Last name: ____________________ First name: _______________ Initial: ___
Group: _____________________
Swimmer 2
Last name: ___________________ First name: ________________ Initial: ___
Group: _____________________
Swimmer 3
Last name: ____________________ First name: _______________ Initial: ___
Group: _____________________
At time of Registration: Parents of the above indicated swimmers are responsible for payment in full for each and all Team Registration Fees, AZ/USA Yearly Registration Fees ($61.00) per Swimmer.
One-time Registration Fee $ 30.00
First Month Training Fee $__________
AZ/USA Yearly Registration $ 61.00
Optional Team Cap $15.00 $__________
Total (made out to Sunwest) $__________
Pre-Authorized Payments
Option 1: I will provide monthly automatic payments to SunWest Swimming through my financial institution. Next page has the Automatic Payment System
Name of Parent or Guardian: (please print) ___________________________________________________
Signature of Parent or Guardian: ________________________________________ Date: ______________
Terms and Conditions for Participation1. Training Fees and/or Dues: Training fees are calculated on a 12-month program. Any
swimmer whose dues have not been paid by the first of the following month will not be allowed in the water to practice or compete until dues have been paid. Dues are billed on the 6 th of the prior month and are due by the first of the month. A $10.00 late fee will apply for any unpaid balance after 30 days and $10.00 for every 15 days there after. (One day of swimming in a month constitutes the obligation of dues for that month. No partial months will be billed or credited. Daily attendance is taken by coaches and will be used to verify each month’s billing obligation. SunWest Swimming does not prorate monthly fees nor does it transfer monthly fees or issue refunds under any circumstance.)
2. Yearly Registration: The yearly club registration fee and United States Swimming (USS)
registration fee of $61.00 are not refundable and must be paid prior to the swimmer entering the water.
3. Meet Entry Fees: Swimmers/Parents are responsible for entry fees. Non-attendance at the meet does not eliminate responsibility. Any outstanding entry fees are considered an obligation to SunWest Swimming and payable upon termination with SunWest Swimming. The team will pay entry fees for relays. Initial: _________
4. Team Handbook: Each parent and swimmer is responsible for reading and understand the contents of the SunWest Team Handbook.
5. Returned Checks: Any checks returned to SunWest Swimming for Non-Sufficient funds will be subject to a $25.00 additional handling charge. Initial: _________
6. Withdrawal from SunWest Swimming: Notification of withdrawal whether temporary or permanent, must be submitted in writing 30 days prior to the first month of the withdrawal. Any notification received after that will result in the obligation of dues and financial obligation for that month. Initial: _________
7. Any swimmer and or swimming family can be removed from SunWest by the Head Coach or Owner because of behavior that is deemed detrimental to the overall health of the team. If a swimmer or family is removed from SunWest. SunWest is not responsible for refunding any dues or fees that have been paid or responsible for buying back equipment/clothing that has been purchased.
8. Parent Participation: Parents are essential to helping this team at meets. We need parents/guardians to participate at each meet. Please see the Coach to find out what needs still need to be filled in order to make each event productive, efficient, and an overall excellent experience for your swimmer. Initial: ________
I understand and agree to the above terms and conditions for participation in SunWest Swimming and acknowledge receipt of a copy of these conditions.
Parent/Guardian Signature: ____________________________________Date: ___________
SunWest Swimming, LLC
9201 N. 51st Dr. Glendale, AZ 85302
602-570-2284SunWest Swimming Participants: Save time and money by using our Automatic Payment System (AMRG). For your convenience and with the help of your bank; we can now automatically deduct your monthly fees from your checking account. No more checks to write! No more bills to worry about or missing a payment. Please complete the information below and attach a voided check.
PLEASE PRINT THE FOLLOWING INFORMATION:
Swimmer Name(s): _________________________________________________________
Parent/Guardian: ___________________________________________________________ (As appears on your checking account)
Address: _________________________________________________________________
City:______________________________ State: _________ Zip: ____________________
Phone ( )______________________ Work ( )_______________________________
I/We hereby authorize an automatic debit on my/our account designated below in payment to SunWest Swimming, LLC per attached agreement for monthly fees. The term of this authorization is for the period of swimmers’ involvement with SunWest Swimming as a student team member commencing December 1 st, 2012 and continues until 30 days after written notice is received of your swimmer’s withdraw from the SunWest Swimming Program. Payments are made from your account on or about the 1st day of each month during the period of your relationship with SunWest Swimming. I further understand that any checks/drafts or electronic transactions returned for insufficient funds will be electronically debited from my account plus a return processing fee of $25.00 or higher amount as governed by the State of Arizona.
______________________________________________ ______________________Signature Date
Bank: _______________________________________________ Branch: _________________________
Bank Routing Number (9 digits): ___________________________________________________________
Account Number: _______________________________________________________________________ (PLEASE ATTACH A VOIDED CHECK TO THIS FORM)
For Office Use Only: Start Date: ______/_____/_____ SWS OK’ed ______________
Payment Amount: $____________________ Term: _____________________
Ending Date: _________________ Date Rec’d AMRG by: ____________________
AMRG Processor/Time: ______________________ DB _____________________