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EDGEWOOD EELS

2012 SWIM TEAM REGISTRATION FORM

*CHILDREN MUST BE ABLE TO SWIM TWO LENGTHS
OF THE POOL TO PARTICIPATE ON SWIM TEAM*

*Required Fields

Swimmer 1 Name*
Date of birth*
Swimmer 2 Name
Date of birth
Swimmer 3 Name
Date of birth
Swimmer 4 Name
Date of birth
Swimmer 5 Name
Date of birth
Swim Team Fees First Child - $ 125.00 Each Additional Child in Family - $25.00
First Child	$ 125.00
Number of Additional Children	x $25.00
Total $
NOTE: Gate fees of $200 per child will apply to all Regular Members and are payable with registration fees.
MEMBER INFORMATION
Name*
Level of Membership*
Street*
City*
State*	PA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip*
Email Address*
Phone*
PAYMENT
Name on card*
Credit Card Number*
Exp. Date valid thru 10.31.2012*	01 02 03 04 05 06 07 08 09 10 11 12 2012 2013 2014 2015 2016 2017
Card type*	Visa Master Card Discover American Express
Credit Card Billing Address (only if different than listed above)
Street Address
City
State	PA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip
	As the credit card holder, I hereby authorize The Edgewood Club, to charge my credit card for the selected membership category and future fees verbally approved by me. *
	I have read the WAIVER RELEASE OF RESPONSIBILITY (CLICK HERE) AND I HAVE FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE*
Any medical/health problems of which the staff should be aware.