Triton Swim Team Registration Form

Name of Swimmer: ___________________________ Preferred Name: ___________________ DOB:______/_______/______ Age_____ School/Grade: _______________________________ Address: _____________________________________________________________________ City/State/Zip: ___________________________________ Phone:________________________ Email: ______________________________________ Parent Contact: _______________________________ Parent Email: ___________________________________ Phone: ________________________ Number of years in competitive swimming? ________ Previous Team _____________________ Best Event (1) _______________________________ Time: _____________________________ Best Event (2) _______________________________ Time: _____________________________ Best Event (3) _______________________________ Time: _____________________________ Session Registering For: Fall Winter Spring Group Placement: ___________________________________________(Determined by coaches) Payment: Make Checks Payable to Marple Newtown Recreation. $100 Annual Registration Fee (covers USA Swimming Registration and Team Joining Fee) Due at Registration. This secures a place in the session. Fall Session Payment due August 22nd, 2015 (September 8, 2015 to November 15, 2015) Senior $300 + $15 Recreation fee = $315 Gold $275 + $15 Recreation Fee = $290 Silver $235 + $15 Recreation Fee = $250 Bronze $200 + $15 Recreation Fee = $215 Winter Session Payment due November 1, 2015 Senior $540 + $15 Recreation fee = $555 Gold $495 + $15 Recreation Fee = $510 Silver $405 + $15 Recreation Fee = $420 Bronze $360 + $15 Recreation Fee = $375

Spring Session Payment due March 15, 2016 Senior $300 + $15 Recreation fee = $315 Gold $275 + $15 Recreation Fee = $290 Silver $235 + $15 Recreation Fee = $250 Bronze $200 + $15 Recreation Fee = $215 Emergency Contact: ______________________________ Phone:________________________ Name of Insurance plan:_________________________________________________________ Policy No. __________________________________ Group No. _________________________ Medical Condition: __________________________ Allergies ___________________________ Name, Address & Phone of Father’s Employer: ______________________________________________________________________________ Name, Address & Phone of Mother’s Employer: ______________________________________________________________________________