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: (____)_______________________________