First Name

*

Last Name

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Email

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Phone

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Cell Phone

Date of Birth

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Address

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State

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Zip

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Grade Level

Coach's Name

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Insurance Provider

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Policy Number

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Are there any health problems that the coaching staff should be aware of ?

Yes
No

If yes, please list them here:

I certify that the information contained in this registration form is complete and true to the best of my knowledge and ability. I hereby hold Grand Rapids Community College harmless with respect to any injury, accident, medical or dental expense, or any other claim that could or might arise as a result of participation in the Gator Swim Program, be it at the facilities of the Grand Rapids Community College Ford Natatorium, or at other facilities. In the event of an injury or other medical emergency, full consent is hereby given for the initial on-site treatment, medical transport, and hospital emergency room care to be administered until such time as a parent or guardian can be located. The extent of steps taken or treatment provided will be determined by the nature of the emergency and evaluation of medical staff.

I confirm that all the information submitted here is accurate