Print Friendly Application (Please print, fill-out and mail this application)

Sleepy Hollow AQuatics - Winter 2011/2012

Name:_________________________________Age:_____Birthdate:________

Program enrolled in:______________________________________________

Address:_______________________________________________________

Phone:________________________________________________________

Email:_________________________________________________________

USA Water Polo #________________________________________________

Medical conditions to be aware of:___________________________________

______________________________________________________________

• 10% off for 2nd and 3rd children from the same family (fill out a seperate application for each child).
• All Athletes must be registered with USA Water Polo Insurance to belong to our club.
• Checks payable to SHAQ.
• Mail to: Sleepy Hollow Aquatics, 29 Angela Ave., San Anselmo, CA 94960
• Questions? Call Mark Anderson at (415) 455-5952 or e-mail: SleepyHollowAquatics@gmail.com

I understand that the Sleepy Hollow Aquatic Club is a competitive program whose meets and training sessions require my child to do strenuous exercise. As a parent or guardian, I agree to assume full responsibility for any injury or sickness resulting from the applicant's participation in any Sleepy Hollow Aquatics activity. I further hold harmless the Sleepy Hollow Aquatics, it's coaches and the Tamalpais High School District for any consequences of such injury or sickness. I authorize and give consent to Mark Anderson or his qualified assistants to seek emergency medical treatment in the event it is needed.

Parental/Guardian Signature:______________________________________

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