Membership Registration for Masters Swim Team

2011-2012 Season

Information on Member

 

Join Date:_____________________

 

 

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Last Name, First Name, MI                                Sex (M/F)                Birthday (mm/dd/yyyy)

 

 

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Street Address                                                  City                                State       Zip

 

 

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Home Phone                                                        Email Address

 

 

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Work Phone                                                         Occupation

 

Billing Options (circle one):   One-Time          Monthly          Quarterly           Auto-Billing Monthly          Auto-Billing Quarterly

 

Any medical considerations we should be aware of?

 

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I ACKNOWLEDGE THAT BY REGISTERING FOR THE MASTERS SWIM TEAM I AM COMMITTED TO PAYING A FULL YEAR’S PROGRAM FEE OF $684.  REGISTRATION FORM AND FIRST PAYMENT IS DUE BY OCTOBER 1, 2011.

 

Signature: ______________________________________

 

Name: _________________________________________Date: __________________