Water Polo Registration

WATER POLO REGISTRATION

All members of Modesto-Stanislaus Water Polo must register with MSWP and USA Water Polo.

Click here to register with MSWP.  This is a link to the email list and is NOT the formal registration regarding dues, etc.  The password to this link is “member”    We will register members on the deck – the cost is $250 for the season lasting from Feb. all the way to the end of July.  When you come to the pool to register please make the check out to MSWP, Inc.     You also will need to bring your health insurance information.

USA Water Polo registration

Registration Form Water Polo – 2012

 

ALL COMMUNICATION IS BY EMAIL    Email address ____________________________

 

Name ____________________________________  DOB ________  M or F (circle)

 

Name ____________________________________  DOB  ________ M or F (circle)

 

Name ____________________________________  DOB  ________ M or F (circle)

 

Address __________________________________________________

 

City       ___________________    Zip code ________    Shirt size _________

Parents names ____________________________________________________________

Contact Information:

 

Phone ____________________       Cell phone ____________________

 

If you would like information sent to additional email address please list below:

_____________________________     ______________________________

 

 

 

 

 

Season you are signing up for:

 

 

 

Pre high school – Feb. 27^th to May 2^nd     _____________   cost $100   (2 days a week)

 

 

 

Summer – May 14^th to July 26^th               _____________   cost $250   (4 days a week)

 

 

 

Checks made to:  MSWP, Inc.

 

Individuals must become members of USA Water Polo if they plan to play in any tournaments or games.  If you are planning on playing in tournaments the minimum level is “silver.”  If you are on the Junior Olympics team you must have a “gold” membership.  The link to sign up online is:

 

www.usawaterpolo.org            The club number is  176

 

Modesto/Stanislaus Emergency Medical Information

 

Participant name _____________________________Present Age______ DOB ________

Sex:  M / F

Father/Guardian  _____________________________ Contact number _______________

Mother/Guardian _____________________________ Contact number _______________

 

In the event of emergency and parents/guardians cannot be reached, call

Name _______________________ Phone # _____________ Relationship ____________

Name _______________________ Phone # _____________ Relationship ____________

 

In the event of an accident or other emergency, I hereby authorize a representative of MSWP to make such arrangements considered necessary for my child to receive medical or hospital care, including transportation under such circumstances.  I further authorize the physician named below or any licensed physician or surgeon to undertake such care and treatment of my child as he/she considers necessary

 

Insurance carrier __________________________________ Medical number ______________

Physician Name __________________________________  Phone number _______________

 

The undersigned hereby agrees to bear all costs incurred as a result of the foregoing, and this authorization will remain in effect until revoked by

X ________________________________ Date ________________

Mother/Guardian Signature

X ________________________________ Date ________________

Father/Guardian Signature

 

 

Does your child have any allergies of which we should be aware of ? (circle)  yes / no

If yes, please list and explain _____________________________________________________

Are there any previous injuries, handicaps, illness, or disease we should be aware of (cir)  yes/ no

If yes, please list and explain _____________________________________________________

Does your child currently take any medication? (circle)  yes / no

If yes, please list and explain _____________________________________________________

 

 

 

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