Registration – Poland Swim Club

Swimmer’s Full Name(Required)

Age as of 6/1/2024(Required)

Date of Birth(Required)

Shirt Size(Required)

Street Address

City

State/Zip

Mother’s Name

Employer

Work or Cell Number

Father’s Name

Employer

Work or Cell Number

Contact if parents are unavailable: relationship/phone #

Doctor’s Name

Address

Phone Number

Health History: Please list all allergies (drug and/or food).

Please explain any serious or chronic illness:

Known physical, emotional or learning problems:

Any conditions that coaches should be aware of:

Please list all medications taken regularly:

Parent/Guardian Signature(Required)

Relationship to Swimmer

Date