2018PIRANHAS

REGISTRATION PACKET

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2018 Fall/Winter Meet Schedule

Dates Hosts LocationsSept. 22 GCAT Pentathlon Savannah

Oct. 20-21 Riptides Octoberfast ConyersNov. 17 Freestyle Frenzy SavannahDec. 1-3 Gator Holiday Classic Gainesville

Jan. 19-20 GT Winter Kickoff Atlanta

Meets attending and dates may be subject to change

First, Middle, Last Name: ____________________________________ Age:______ Gender:______ DOB: _________________

Address: ______________________________________________ City: __________________________ Zip:______________

Phone: ______________________ Cell: ___________________ E-Mail: ____________________________________________

Mother’s Name: __________________________________ Employer: _________________________________________

Work Address: ____________________________________ Work Phone: _______________________________________

Cell: ______________________________ E-mail:________________________________________

Father’s Name: ___________________________________ Employer: _________________________________________

Work Address: ____________________________________ Work Phone: _______________________________________

Cell: ______________________________ E-mail:________________________________________

Emergency Contact Other Than Parents:

Name: ____________________________ Relationship: ________________________ Phone : _________________________

Name: ____________________________ Relationship: ________________________ Phone : _________________________

Please list any conditions that might limit participation in this program (medical or disability):

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Individuals (other than parents) allowed to pick up this child:

Name/Relationship: ________________________________ Name/Relationship: _________________________________

Address: ________________________________________ Address: __________________________________________

Phone: __________________________________________ Phone: ___________________________________________

Copy of your child’s birth certificate for District & State Meet verification

Received: _________________________________Date: _________________________ Initials: _________________________

Emergency Medical Authorization

Should _________________________________________ suffer an injury or illness while in the care of the Valdosta YMCA, Child’s Nameand the facility is unable to contact me immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) agree to keep the facility informed of changes in telephone numbers, etc. where I can be reached. The facility agrees to keep me informed of any incidents requiring professional medical attention involving my child. Child’s pri-mary source of health care is ___________________________________________ ____________________________ Physician/Clinic Name Phone

Known medical condition (i.e. diabetic, asthmatic, drug allergies): ___________________________________________________

_______________________________________________________________________________________________________

Parent or Guardian Signature: ________________________________________________ Date: ________________________

2018 YMCA PIRANHA SWIM TEAM REGISTRATION FORM

TEAM PLACEMENTTeam Date Coach

___________ ___________ ___________

VALDOSTA-LOWNDES COUNTY FAMILY YMCA RELEASE & WAIVER of LIABILITY & INDEMNITY AGREEMENT

IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby ac-knowledges, agrees and represents that he or she has, or immediately upon entering or participating, will inspect and care-fully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation. Kids under the age of 16 must be accompanied by an adult 18 years or older at all times at the YMCA. Only personal trainers employed by the YMCA may train clients at the YMCA facility.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents (hereinafter referred to as “releases”) from all liability to the under-signed, his/her personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releases or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA.

2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any loss, liability, damage or cost that may incur due to the presence of the undersigned in, upon, or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participat-ing in any program affiliated with the YMCA whether caused by the negligence of the releases or otherwise.

3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of release or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Georgia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEM-NITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

I HAVE READ THIS RELEASE

________________________________________________ __________________________________________ Signature of Applicant (parent or guardian if under 18) Signature of Spouse

________________________________________________ __________________________________________ Print Name Print Name

________________________________________________ __________________________________________ Date Date

2018 REGISTRATION FEE USA Swimming Fee $30.00 LSC Fee TOTAL DUE

USA SWIMMING 2018 SEASONAL ATHLETE REGISTRATION APPLICATION LSC: CHECK APPROPRIATE SEASONAL PERIOD: THIS MEMBERSHIP IS ONLY FOR MEETS BELOW

SEASON 1 SEASON 2 INDIVIDUAL SEASON ZONE, SECTIONAL AND NATIONAL LEVELS.

PLEASE PRINT LEGIBLY ⚫ COMPLETE ALL INFORMATION: LAST NAME LEGAL FIRST NAME MIDDLE NAME PREFERRED NAME DATE OF BIRTH (MO/DAY/YR) SEX (M/F) AGE CLUB CODE NAME OF CLUB YOU REPRESENT

(Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter “Unattached” GUARDIAN #1 LAST NAME GUARDIAN #1 FIRST NAME GUARDIAN #2 LAST NAME GUARDIAN #2 FIRST NAME MAILING ADDRESS U.S. CITIZEN: YES NO CITY STATE ZIP CODE AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD E-MAIL ADDRESS

OPTIONAL DISABILITY: RACE AND ETHNICITY (You may A. Legally Blind or Visually Impaired check up to two choices): B. Deaf or Hard of Hearing Q. Black or African American C. Physical Disability such as R. Asian

amputation, cerebral palsy, S. White dwarfism, spinal injury, T. Hispanic or Latino mobility impairment U. American Indian & Alaska Native

D. Cognitive Disability such as V. Some Other Race severe learning disorder, W. Native Hawaiian & Other Pacific

autism Islander HIGH SCHOOL STUDENTS – Year of high school graduation: SIGN HERE x ___________________________________________________________________ ____________________ SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE ONLY ____________________

MAKE CHECK PAYABLE TO:

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MAIL APPLICATION & PAYMENT TO:

YEAR LAST REGISTERED: . IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2017, ENTER THAT CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB: .

Check if you would like to learn more about the USA Swimming Foundation’s initiatives Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older)

ARE YOU A MEMBER OF ANOTHER FINA FEDERATION? ☐ YES ☐ NO

IF YES, WHICH FEDERATION: HAVE YOU REPRESENTED THAT FEDERATION AT INTERNATIONAL COMPETITION? ☐ YES ☐ NO YMCA

$30.00

2017 REGISTRATION FEESept. 1, 2016 through Dec. 31, 2017USA Swimming Fee $56.00LSC Fee $18.00TOTAL DUE $74.00

LORA THOMPSON2365 COBBLE CREEK LANEGRAYSON, GA 30017registrar@gaswim.org

USA SWIMMING 2017 ATHLETE REGISTRATION APPLICATION LSC: GEORGIA SWIMMING (GA)

PLEASE PRINT LEGIBLY COMPLETE ALL INFORMATION: LAST NAME LEGAL FIRST NAME MIDDLE NAME

PREFERRED NAME DATE OF BIRTH (MO/DAY/YR) SEX (M/F) AGE CLUB CODE NAME OF CLUB YOU REPRESENT

(Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter “Unattached” GUARDIAN #1 LAST NAME GUARDIAN #1 FIRST NAME GUARDIAN #2 LAST NAME GUARDIAN #2 FIRST NAME

MAILING ADDRESS

U.S. CITIZEN: YES NOCITY STATE ZIP CODE

AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD E-MAIL ADDRESS

OPTIONAL DISABILITY: RACE AND ETHNICITY (You may A. Legally Blind or Visually Impaired check up to two choices): B. Deaf or Hard of Hearing Q. Black or African American C. Physical Disability such as R. Asian

amputation, cerebral palsy, S. White dwarfism, spinal injury, T. Hispanic or Latino mobility impairment U. American Indian & Alaska Native

D. Cognitive Disability such as V. Some Other Race severe learning disorder, W. Native Hawaiian & Other Pacific

autism Islander HIGH SCHOOL STUDENTS – Year of high school graduation:

SIGN HERE x ___________________________________________________________________ ____________________

SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE ONLY ____________________

MAKE CHECK PAYABLE TO:

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GEORGIA SWIMMING

MAIL APPLICATION & PAYMENT TO:

YEAR LAST REGISTERED: . IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2016, ENTER THAT CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB: .

Check if you would like to learn more about the USA Swimming Foundation’s initiatives Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older)

ARE YOU A MEMBER OF ANOTHER FINAFEDERATION? ☐ YES ☐ NO

IF YES, WHICH FEDERATION:

HAVE YOU REPRESENTED THATFEDERATION AT INTERNATIONALCOMPETITION? ☐ YES ☐ NO

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2018 REGISTRATION FEE Sept. 1, 2017 through Dec. 31, 2018 USA Swimming Fee $58.00 LSC Fee TOTAL DUE

USA SWIMMING 2018 ATHLETE REGISTRATION APPLICATION LSC: PLEASE PRINT LEGIBLY ⚫ COMPLETE ALL INFORMATION: LAST NAME LEGAL FIRST NAME MIDDLE NAME PREFERRED NAME DATE OF BIRTH (MO/DAY/YR) SEX (M/F) AGE CLUB CODE NAME OF CLUB YOU REPRESENT

(Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter “Unattached” GUARDIAN #1 LAST NAME GUARDIAN #1 FIRST NAME GUARDIAN #2 LAST NAME GUARDIAN #2 FIRST NAME MAILING ADDRESS U.S. CITIZEN: YES NO CITY STATE ZIP CODE AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD E-MAIL ADDRESS

OPTIONAL DISABILITY: RACE AND ETHNICITY (You may A. Legally Blind or Visually Impaired check up to two choices): B. Deaf or Hard of Hearing Q. Black or African American C. Physical Disability such as R. Asian

amputation, cerebral palsy, S. White dwarfism, spinal injury, T. Hispanic or Latino mobility impairment U. American Indian & Alaska Native

D. Cognitive Disability such as V. Some Other Race severe learning disorder, W. Native Hawaiian & Other Pacific

autism Islander HIGH SCHOOL STUDENTS – Year of high school graduation: SIGN HERE x ___________________________________________________________________ ____________________ SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE ONLY ____________________

MAKE CHECK PAYABLE TO:

–

MAIL APPLICATION & PAYMENT TO:

YEAR LAST REGISTERED: . IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2017, ENTER THAT CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB: .

Check if you would like to learn more about the USA Swimming Foundation’s initiatives Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older)

ARE YOU A MEMBER OF ANOTHER FINA FEDERATION? ☐ YES ☐ NO

IF YES, WHICH FEDERATION: HAVE YOU REPRESENTED THAT FEDERATION AT INTERNATIONAL COMPETITION? ☐ YES ☐ NO YMCA

2017 REGISTRATION FEESept. 1, 2016 through Dec. 31, 2017USA Swimming Fee $56.00LSC Fee $18.00TOTAL DUE $74.00

LORA THOMPSON2365 COBBLE CREEK LANEGRAYSON, GA 30017registrar@gaswim.org

USA SWIMMING 2017 ATHLETE REGISTRATION APPLICATION LSC: GEORGIA SWIMMING (GA)

PLEASE PRINT LEGIBLY COMPLETE ALL INFORMATION: LAST NAME LEGAL FIRST NAME MIDDLE NAME

PREFERRED NAME DATE OF BIRTH (MO/DAY/YR) SEX (M/F) AGE CLUB CODE NAME OF CLUB YOU REPRESENT

(Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter “Unattached” GUARDIAN #1 LAST NAME GUARDIAN #1 FIRST NAME GUARDIAN #2 LAST NAME GUARDIAN #2 FIRST NAME

MAILING ADDRESS

U.S. CITIZEN: YES NOCITY STATE ZIP CODE

AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD E-MAIL ADDRESS

OPTIONAL DISABILITY: RACE AND ETHNICITY (You may A. Legally Blind or Visually Impaired check up to two choices): B. Deaf or Hard of Hearing Q. Black or African American C. Physical Disability such as R. Asian

amputation, cerebral palsy, S. White dwarfism, spinal injury, T. Hispanic or Latino mobility impairment U. American Indian & Alaska Native

D. Cognitive Disability such as V. Some Other Race severe learning disorder, W. Native Hawaiian & Other Pacific

autism Islander HIGH SCHOOL STUDENTS – Year of high school graduation:

SIGN HERE x ___________________________________________________________________ ____________________

SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE ONLY ____________________

MAKE CHECK PAYABLE TO:

–

GEORGIA SWIMMING

MAIL APPLICATION & PAYMENT TO:

YEAR LAST REGISTERED: . IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2016, ENTER THAT CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB: .

Check if you would like to learn more about the USA Swimming Foundation’s initiatives Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older)

ARE YOU A MEMBER OF ANOTHER FINAFEDERATION? ☐ YES ☐ NO

IF YES, WHICH FEDERATION:

HAVE YOU REPRESENTED THATFEDERATION AT INTERNATIONALCOMPETITION? ☐ YES ☐ NO

$58.00

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Valdosta-Lowndes County Family YMCA – Swim Team Monthly Automatic Payment Agreement

(Please choose either Credit Card Draft or Bank Draft) Child(ren) Name(s): Name(s) of Parent(s)/Guardian(s): Mailing Address:

City: State: Zip: Phone: Amount of Child Care Fee: $ per month AGREEMENT:

1. The Valdosta YMCA Piranha Swim Team monthly debit is a continuous payment plan, and fees are due on the first of each month. I understand that this plan will remain in effect until I wish to terminate my child(ren)’s enrollment in the YMCA Piranha Swim Team.

2. It is to my complete understanding that if I wish to terminate or change my Swim Team payment in any way, I must give the Valdosta YMCA WRITTEN NOTICE PRIOR TO THE 21st OF THE MONTH PRIOR TO MY NEXT DEBIT DATE. If proper notice is not received, I will be held responsible for tuition regardless of whether or not my child attends the Valdosta YMCA Swim Team.

3. Should any debit not be honored by my bank/credit card company for any reason, I understand that I am still responsible for the payment, plus a $25.00 service charge applied by the YMCA. This is in addition to any service fee my bank/credit card company may require.

CREDIT CARD DRAFT:

Credit Card Type (Please circle): VISA MASTERCARD DISCOVER

Name of Cardholder (as it appears on the card):

Card Number: - - - Exp. Date of Card: 3 digits on back:

I (we) hereby authorize the Valdosta YMCA to debit the above credit card on the date and for the amount indicated each week for my child care services.

Card Holder’s Signature Date

Valdosta-Lowndes County Family YMCA, 229-244-4646, POB 1301 Valdosta, GA 31603 YMCA Mission: to put Christian principals into practice through programs that build healthy spirit, mind and body for all.

Visit us anytime on the web at Valdostaymca.org

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Valdosta YMCA Piranhas Swim Team Checklist

The Valdosta YMCA Piranhas Swim Team is a year-round swim club that offers comprehensive training and instruction for all kids of any ability. We offer multi level group placement from

the first time swimmer to the most advanced athlete. We are a member club of United States Swimming, competing in USA sanctioned meets throughout the year, as well as, GRPA

Summer League Swim Meets during the summer months.

*** MUST COMPLETE CHECKLIST TO BEGIN SWIMMING***

_____ 1. Complete the Attached Registration Application

_____ 2. Complete Auto-Draft Form

_____ 3. Complete the Attached USA Swimming Registration Form (Year-Round or Seasonal)

_____ 4. Check Payable to the YMCA for USA Swimming Fees Seasonal $30 or Year-Round $58

_____ 5. Copy of Swimmer’s Birth Certificate

_____ 6. Check Payable to the YMCA for the 1st Month’s Program Fees

_____ 7. Pass the Swim Test and Be Placed in a Group Administered by Coach