Registration Information

Swimmer and Parent/Guardian Information

Swimmer's Name

Date of Birth

Address

Phone

Cell

School

Grade

Email*

Parent/Guardian Name

Is Parent Guardian information different from above?

Yes

No

If yes, please list contact information for parent/guardian.

Address

Phone

Please list swimmer's health conditions or allergies

Is swimmer currently taking any medication?

Yes

No

If yes, please list medications.

Swimmer's health insurance

Policy #

Full Name

Relationship to child

Phone number

May we contact you or the swimmer by text messages?

Yes

No

May we contact you or the swimmer by email?

Yes

No

I declare that the info I’ve provided is accurate and complete.

How did you hear about this program? (if other, fill in below)

Flyer

Social Media

ECS Website

Newspaper

Word of Moth

Other (Please let us know where you heard about us)

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