ELITE MEMBERSHIP FORM
Legal
First Name:___________________Middle Initial: _________
Preferred
First Name: _____________________________________
Birth
Date: ____________________________Age:______________
Address:
________________________________________________
City/Town:
____________________________Zip:______________
Home
Phone: ____________________________________________
Swimmer
Email Address:___________________@ ______________
Parent
Email Address: _____________________@______________
Third
Email Address: ______________________@______________
Mother’s
Name: _________________________________________
Work/Cell #:
(_____)________________________________
Father’s
Name: __________________________________________
Work/Cell #: (____)_________________________________
Emergency
Contact w/ phone number: ______________________
(____)_______________________________________
Doctor:
_________________________________________________
Office
Phone Number: (____)_______________________________