Norwin Aqua Club

Emergency Contact Form

 

SWIMMER INFORMATION:

 

NAME: ___________________/___________________/______   PHONE #: ___________________

              (Last)                               (First)                             (MI)

 

ADDRESS: ________________________________________________________________________    

 

                    ________________________________________________________________________

 

************************************************************************

PARENT / GUARDIAN INFORMATION:

 

1.) Guardian Name: __________________/_____________________/_________________________

                                    (Last)                           (First)                                  (Relationship to Child)

 

2.) Guardian Name: __________________/_____________________/_________________________

                                    (Last)                           (First)                                  (Relationship to Child)

 

PHONE NUMBERS:  (include area code)

 

            Home: ___________________    Work: ____________________    Cell: __________________

 

************************************************************************IN THE EVENT OF AN EMERGENCY, WHOM SHOULD WE CONTACT IF THE GUARDIAN CANNOT BE REACHED:

 

Name: __________________/_____________________/_________________________

            (Last)                           (First)                                  (Relationship to Child)

 

Address: ____________________________________________________________________________

 

PHONE NUMBERS:  (include area code)

 

Home: ___________________    Work: ____________________    Cell: __________________

 

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