Glen Gators Swim Team
Registration Form – Fall/Winter 2016-2017
Name Swimmer 1
First
Middle
Last
School
Sex
Grade
M
F
Birthdate
Age
Name Swimmer 2
First
Middle
Last
School
Sex
Grade
M
F
Birthdate
Age
Address
Home Phone
City
State
Zip
Email
Email
Cell Phone
Mom
Cell Phone
Dad
Fall/Winter Season Rates 2016-17: (October 2016-March 2017)
USA Swimming Insurance
$69.00
NON REFUNDABLE
(Must be paid the first week of practice)
Club Dues
Group 1
$176.00
Group 2
$196.00
Group 3
$226.00
Each additional swimmer*
$176.00 each additional swimmer
* Regular club dues will be charged for the swimmer in the highest group
Signature of parent/guardian__________________________________________Date__________
The person whose signature appears above agrees to make payment for the Glen Gators session
fee and USA swimming fee indicated on the rate table. This person is responsible for the
complete payment of all fees owed to the club by the indicated dates. Failure to do so will
suspend the above swimmer(s) from participation in all club activities, including practice and
competition, until payment is received. The signer therefore agrees that the swimmer is
contracting to swim with Glen Gators for this designated session(s) and that all dues/fees will be
paid regardless of the swimmer’s frequency of participation in the club for that session.
(OVER)
Payment Record GGST Fall/Winter 2016-2017
Swimmer #1
Amt
Date
Paid
Received
Swimmer #2
Amt
Date
Paid
Received
Cash or
Check#
Cash or
Check#
USA Insurance Fee
Payment due within first week of practice
Club Dues
Payment due within two weeks of registration
Additional Payments (Meet Fees, Apparel Orders, ect.)
Payment Description
Swimmer
Amt Paid
Date Received
Cash or Check#
Glen Gators Swim Team Agreement
I, ________________________________, the parent/guardian of ________________________________________________
Agree to allow my child(ren) and family members to participate in the Glen Gators Swim Team (hereafter called GGST), and
hereby release GGST, the coaches, staff, and board members of GGST, and the facilities used by GGST and their agents and
employees from any injury that may occur to myself, my child(ren), or family members while participating with GGST,
including travel to and from training session and scheduled activities. I agree to indemnify and hold harmless the above
mentioned, their agents and employees against all liability for personal injury, including injuries resulting in death, or damage
to property, or both while I, my child(ren), or family members are participating in the program. I agree to reimburse the
above-mentioned parties for any damages they are compelled to pay arising from such claims, demand, action, or cause of
action by me, my child(ren), or family members.
I have read the above statement and understand its contents.
Signature of Parent/Guardian________________________________________________________Date_______________