Mechanicsburg Swim Club
2016 Summer Swim Season Team Registration Form
Office Use:
Check #
The MSC Summer Season begins April 25, 2016
Registration April 25, 6:00-8:00 PM
Time Trials Wednesday June 1 (Time will be posted)
Cash
Balance Due:
PIF:
Please fill out all the information completely and legibly - bear in mind that the information provided
might one day be used to contact you or others in the case of emergency. DO NOT use phone numbers
or email addresses that you do not regularly use. Incomplete forms will NOT be accepted.
* High School swimmers are expected to assist the coaches and act as mentors to the age group swimmers.
* Signed registration form, signed parent/swimmer code of conduct, and payment
including volunteer fee (see below) must be submitted prior to June 1st.
* A 50% deposit is required at the time of registration.
* Registration fees must be paid in full prior to the first swim meet.
* Registration forms received after June 1st will be charged an additional $25 late registration fee.
* Registration does not cover participation in invitational meets and/or USA Swimming meets
which may carry additional participation fees.
* Payment may be made by cash or check (payable to the Mechanicsburg Swim Club).
* A $25 fee will be charged for any returned checks. Credit cards are not being accepted.
* All swimmers are required to have a "team" suit for use at competitive events.
* It is the parent or guardians responsibility to purchase the TYR Phoenix Splice Diamond Fit suit in black/burgundy.
* Swim suit can be ordered online. MSC will have sizing suits for anyone who needs to order suits.
* MSC Caps will be provided for New swimmers only. Replacement caps for returning swimmers can be purchased for $10.00.
Pool passes required to participate at outdoor practices.
Please see page 2 for details.
High School Swimmer's Home School District - Must be MASH to qualify.
M E C H A N I C S B U R G
Swimmer Name(s)
Swimmer Name:
Phone Y/N text
.
.
S E N I
O R
H I
G H
S C H O O L
$
2 5
phone & email not required just helpful.
email
Registration Fee Per Swimmer:
Quantity @ $25 each =
$
Volunteer Clearances Required! Please visit website for details and forward to Leon Crone by June 1st, 2016.
$
Late Registration Fees - after 6/1/2016 $25 =
Total Fees:
$
Parent/Guardian Contact Information
Parent/Guardian
Street
Apt:
City, State zip
P A
1st Phone Y/N text
.
.
Alt phone Y/N text
.
.
email
Alternate email
2nd phone Y/N text
.
Zip:
.
Circle Y or N for text for each phone # provided.
Mechanicsburg Swim Club
2016 Summer Swim Season Team Registration Form
Permission to use your child's (unidentified) team related photo's on the club website:
YES
NO
Permission to use your child's (unidentified) team related photo's on the club Facebook page:
YES
NO
I, the parent/guardian of the applicant(s), hereby give my permission for my child(ren) to participate in the swim
team activities during the winter season. I absolve, indemnify, and hold harmless the Mechanicsburg Swim
Club, Mechanicsburg School District, Mechanicsburg Parks and Recreation Commission and team Coaches,
Officials and Board of Directors. I likewise wave to the extent not covered by liability insurance, any claim
against any person transporting my child(ren) to and from activities. I will furnish, if requested a certified birth
certificate for the applicant and further certify that the child is in good health and physically able to participate
on a swim team. I have read, understand, and will comply with the payment terms outlined on the previous
page. Should my child(ren) have a change in his/her medical condition, I will contact the MSC board immediately.
Parent/ Guardian Signature
Date
Swimmer Medical Emergency Information
Child #1:
Date of Birth:
M/F
Age on 6/1/2016
Allergies or chronic problems (ex. Asthma, Heart Murmur, etc.):
Current Medications:
Special Comments:
Family Doctor:
Phone:
.
.
Alternate or weekend #
.
.
.
.
Health Insurance
Provider:
Insurance ID#
Emergency Contact
Other than Parents:
Relationship to Child:
1st Phone Y/N text
.
.
http://www.mechanicsburgswimclub.com/
2nd phone Y/N text
Coach Mike G. 717-503-1831