TRI-M CYO SWIM TEAM

2017/2018
SWIMMING PROGRAM FOR BOYS

NAME OF SWIMMER DIVISION

PRESENT AGE DATE of BIRTH

PARENTS NAME SCHOOL

PARISH

ADDRESS GRADE

CITY & ZIP MEDICAL INFO

(Asthma,allergies,etc.)

HOME PHONE CELL PHONE mother

E-MAIL ADDRESS father

PRINT CLEARLY

I hereby give my child________________________________________permission to participate in the TRI-M CYO swim program. I authorize a coach, trained lifeguard
or adult representative of the team to provide emergency treatment of an injury or illness to my child. This authorization is granted only if I cannot be
reached and a reasonable effort has been made to do so.

Parent or Guardian's Signature______________________________________________

I understand that this team/program operates solely on the swim fees paid by the participants. All personnel are volunteers except for the lifeguards.
I hereby agree to volunteer my time for locker room duty as the program needs me.

Parent or Guardian's Signature______________________________________________

If you have any questions, please call Mary Leong 718-793-4082

TEAM______

CLUB________

FOR OFFICE USE ONLY

PAID__________________ CHECK# OR CASH____________ HS_______