What masters swimmer name

WHAT Masters

SWIMMER NAME: __________________________ ______ ___________________________

First MI Last

ADDRESS: _______________________________________ ____________________________ __________ ______________

Street City/Town State Zip
HOME PHONE:_______________________ CELL PHONE:_______________________________

BIRTH DATE:________________________ SEX (M/F)____________

EMAIL ADDRESS: __________________________________________________________________________
EMPLOYER:_____________________________________________________________________

PROFESSION: ___________________________________________________________________

WORK PHONE: __________________________________________________________________

WORK EMAIL ADDRESS: __________________________________________________________

MEMBERSHIP TYPE:

$70.00 per month for unlimited practice:____________

$40.00 per month for 12 workouts per month:____________

$20.00 WHAT Masters Registration fee- this is included only at your initial registration for processing paperwork

Make your check payable to WHAT Swimming (sorry, no credit cards) and mail application and payment to:

WHAT Swimming

113 Ballard Drive

West Hartford, CT 06119

*** All members of WHAT Masters must have a current United States Masters Swimming card
SWIMMER PROFILE
The following information will help us provide an effective program consistent with the goals and profiles of the

swimming community.

I started fitness or competitive swimming at age ______.
I have recently been swimming ______ times a week.
What is the fastest interval for which you can hold 5 x 100 yard freestyle repeat? _________________
My swimming history is:___________________________________________________________________
I am primarily a: fitness swimmer ______ competitive swimmer ____ triathlete____
I plan on swimming mostly: mornings___ lunch ___ weekend____


WHAT Masters
Medical Release Form

(This release is effective for the period of September 1, 2014 - August 31, 2015)
The undersigned, ____________________________ does hereby (1) authorize the WHAT Masters, its agents, officers and employees to seek such medical treatment or assistance them may deem necessary or appropriate in the event of an accident or medical emergency (2) confirm that the undersigned has no medical, physical or other condition(s) which would impede or interfere with the undersigned's participation in the activates of the WHAT Masters and (3) indemnify and hold harmless the West Hartford Aquatic Team, University of Saint Joseph and Miss Porter’s School, their officers, directors, employees, officials, boards and an missions from all liabilities, damages, claims, demands and actions of whatever nature in any way relating to or arising out of the undersigned's use of the facilities of the University of Saint Joseph College, Miss Porter’s School and any and all activities undertaken at such facilities or sponsored by the WHAT Masters, even if undertaken elsewhere.
In the event the undersigned needs emergency medical care while on the WHAT Masters, I hereby give permission for the hospital to give such emergency treatment as is considered necessary and based upon the appropriate medical judgment, including the administration of anesthesia.
___________________________________________ ____________

Signature Date

EMERGENCY CONTACT INFORMATION

NAME: ______________________________________________ RELATION:_____________________

ADDRESS: _________________________________________________________________________________

HOME PHONE: _______________________ CELL PHONE: __________________

INSURANCE COMPANY: ________________________________________________

PHYSICIAN: ___________________________________ PHONE: _____________________________

ADDRESS: _________________________________________________________________________________

HOSPITAL PREFERENCE:____________________________________________________________________

KNOWN ALLERGIES: _____________________________________________________________________

PREVIOUS INJURIES/SURGY: ______________________________________________________________

__________________________________________________________________________________________

IF YES, Are you cleared to swim/train? __________________ DATE CLEARED TO SWIM: __________

PHYSICIAN THAT CLEARED YOU:__________________________________________________________
WHAT Masters
ACKNOWLEDGEMENTS AND AGREEMENTS
** Please read each statement below and if you understand and agree place your initials in the space next to the paragraph to signify your understanding and agreement:

______ 1. I agree to pay all applicable fees when due. I further understand that no portion of such fees so paid or outstanding will be refunded or canceled notwithstanding the absence, withdrawal or dismissal of the below swimmer. Monthly payments must be made on time or WHAT Masters may deny swimmer participating in practices and/or meets. I agree to pay a late charge of 1 % per month (12% per year) (simple interest) on any charges which are unpaid 10 days after the due date. I understand that if a payment is unpaid 10 days after the due date I will not be allowed to practice/attend meets until payment is received. I also understand that in the event of a returned check or collection by any attorney or other agency, I accept responsibility for and agree to pay all additional charges, including reasonable collection costs and attorney's fees.

______ 2. I acknowledge to abide by the terms and conditions required by the facilities used by WHAT Masters. Furthermore, the coaching staff reserves the right to discipline and (or) remove a swimmer if adherence to such guidelines and rules are not met by the person named below.
______ 3. In the event I need emergency medical care while on the WHAT Masters, I hereby give permission for the hospital to give such emergency treatment as is considered necessary and based upon the appropriate medical judgment, including the administration of anesthesia.
______ 4. I agree to assume all medical expenses incurred while participating in the WHAT Masters swim program.

Signature_____________________________________________________ Date_________________

ADDITIONAL INFORMATION
How did you hear about WHAT MASTERS:_________________________________________________________
Are you Active Military? Yes:_____________ No:____________
Primary Reason for Joining: ____________________________________________________________________________________________________________________________________________________________________________________
T-Shirt Size (Adult): Small:___ Medium:___ Large:___ X-Large:___ XXL:___