North Shore Swim Club
Signed Release Form - Required for
practice sessions as well as swim meets
Athletes Name: ______________________ D.O.B: ____________SS#___________________
Mother' Name: ________________________ Father's Name: __________________________
Alternate Guardian: ___________________ Relationship to swimmer __________________
Mother:
Day Phone: ___________________ Work Phone: __________________
Cell Phone: ____________________ Pager Number: ________________
Father:
Day Phone: ___________________ Work Phone: __________________
Cell Phone: ____________________ Pager Number: ________________
Alternate Guardian:
Day Phone: ___________________ Work Phone: __________________
Cell Phone: ____________________ Pager Number: ________________
Medical Insurance Carrier (Name & Policy #)
___________________________________________________________________________
Dental Insurance Carrier (Name and Policy #)
____________________________________________________________________________
Family Doctor: _____________________________________ Telephone #: ______________
Medications (List Details): _____________________________________________________
____________________________________________________________________________
Allergies (List/What to Do): ____________________________________________________
____________________________________________________________________________
Please list any past medical/surgical condition (s):
____________________________________________________________________________
____________________________________________________________________________
Release:
I Give permission for (athlete)__________________________ to participate in all
North Shore Swim Club functions. I hereby give for myself, my heirs,
administrators, executors and personnel representatives waive, release and
forever discharge any and all rights and claims for damages which I may accrue
against the North Shore Swim Club, United States Swimming, or their respective
employees which may be suffered by the athlete at said functions. I also hereby
give consent for medical care to be given to my child at the nearest medical
facility available and release any medical information necessary for treatment
to be given.
Parents Signature: __________________________ Date: __________________________