ELITE MEMBERSHIP FORM

Swimmer’s Last Name: ___________________________________

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: (____)_______________________________