Diving Registration Form

Parent/Guardian

PayPal email (if different from above)

Emergency Contact

Emergency Phone

1st Child Name

1st Child Date of Birth

1st Child Grade Level | 2016-2017 School Year

1st Child School

1st Child T-shirt Size

2nd Child Name

2nd Child Date of Birth

2nd Child Grade Level | 2016-2017 School Year

2nd Child School

2nd Child T-Shirt Size

Comment

By submitting this form, I understand that in the event an injury to my child(ren) while in my absence, I allow my child(ren) to be treated by a physician or other medical personnel. This may mean using ambulance and/or hospital services in the local area where the injury was sustained to properly treat said injury.

Just a reminder, t-shirts are given once per calendar year. If you received a t-shirt at an earlier clinic this year, you won’t receive a second one.