2007-2008 BASA Swimmer Information Sheet

DATE________________________________

Swimmer's Full Name:_____________________________________________________

Age:___________ Date of Birth:________________ Years Swimming:______________

Mother’s Name:___________________________________________________________

Address:________________________________________________________________

Phone: Home_________________ Work_________________ Cell__________________

Email:___________________________________________________________________

Father’s Name:___________________________________________________________

Address:_________________________________________________________________

Phone: Home_________________ Work__________________ Cell_________________

Email:___________________________________________________________________

Name of person(s) who have permission to pick swimmer up from swim practice:

Name:___________________________________________________________________

Name:___________________________________________________________________

Emergency Contact:

Name:___________________________________________________________________

Phone:__________________________________________________________________

Name of Family Physician:_________________________________________________

Phone Number:___________________________________________________________

Date of last physical_______________________________________________________

Insurance Company _______________________________________________________

Policy Number ___________________________________________________________

Does your child have any medical problem, which could potentially interfere with his/her ability to safely participate in competitive swimming?

________________________________________________________________________________

________________________________________________________________________________

_________________________________________________________________________________