Application and Emergency Information Form
Personal Information
Child�s Name_________________________________________________________________
Nickname____________________________Age__________Birthdate__________________
Home address_____________________________________________________________________
City______________________State__________________________Zip__________________
Home phone #_______________________________________________________________
Email address________________________________________________________________
Father�s Name_______________________________________________________________
Work #________________________________ Cell #_________________________________
Place of employment_________________________________________________________________
Mother�s Name______________________________________________________________
Work #_________________________________ Cell # _______________________________
Place of employment_____________________________________________________________________________
Emrgency Notification:f not available in an emergency � Notify:
________________________________________________________
Name Phone # Relationship to Child
Has your child participated in competitive swimming elsewhere? ____Where & length of time________________________
Parent support of the team is needed in many ways. Would you be willing to support the team in any of the following ways?
Officiating (training provided) ____ Communication ____Record keeping ____Scorekeeping Fund Raising Timing ____
Locker Room Control (Meets/Practices) ____Publicity/Organizing Social Events _____Clean Up (Meets) ____
I do / do not (circle one) give the Delhi Dolphins permission to use my child�s photograph in news releases or for promotional purposes.
Medical/Emergency Information
______________________________________________________________________________________
Does your child have any medical problems that we should be aware of? (Example � asthma, or operations)
________________________________________________________________________________________________
Does your child routinely take any medications? If so, please list them.
______________________________________________________________________________________
Please list any know allergies (ex. � foods, environmental, medications, etc.)
______________________________________________________________________________________
Physician Name Address Phone #
Please provide Medical Insurance information:
Company ________________________________________Policy/ID #_____________________________
In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the Delhi Dolphins USA Swim Team to hospitalize, secure proper treatment for and to order any injection, anesthesia or surgery for my child as named:______________________________
Parent/ Guardian�s Signature___________________________________________Date______________