Saanich Water Polo School

(250) 514-9236

COMPETITIVE PROGRAM REGISTRATION

Please note that your registration is active once the PAD (Pre Authorized Debit) information is on file.This form has been designed for families to be able to add up to 5 children (siblings) on the same form. Skip name fields that you do not need to use.

Parent / Guarding Information (Primary Contact)

Full Name *

Relationship *

Phone *

Email *

Address (Athlete Home) *

City *

Postal code *

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Parent / Guarding Information (Secondary Contact)

Full Name (Secondary Contact) *

Relationship (Secondary Contact) *

Phone (Secondary Contact) *

Email (Secondary Contact) *

Emergency Contact (Other Than Guardian)

Name (Emergency Contact) *

Relationship (Emergency Contact) *

Phone (Emergency Contact) *

Email (Emergency Contact) *

Athlete (1) Full Name *

Athlete (1) DOB *

Athlete (2) Full Name

Athlete (2) DOB

Athlete (3) Full Name

Athlete (3) DOB

Athlete (4) Full Name

Athlete (4) DOB

Athlete (5) Full Name

Athlete (5) DOB

Do any of the athletes in the family, submitted on this form have any history of chronic illness or other conditions that coaches need to know about, that may impact their performance or their safety while performing strenuous exercise in a group setting. *

Yes

Do any of the athletes submitted on this form carry emergency medication for severe allergies, diabetes, or any other condition? *

Yes

If you selected yes to either of the above, please describe / provide details:

Waiver: I acknowledge and fully understand and agree to assume all risks and hazards involved in and arising out of my child’s activities with Saanich Water Polo School. I hereby waive, release, forego and relinquish any and all claims, demands, suits, actions or causes of action which I may have against the directors, employees, and organization’s activities. In the event that our family doctor can not be contacted or is unable to attend to my child in an emergency, I hereby authorize and direct Saanich Water Polo School to choose a doctor to attend to my child. I further acknowledge and agree that typing my name on the signature line constitutes an electronic signature. My electronic signature is the legal equivalent of my manual signature. *

Waiver Acknowledgment

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