2011 Polo Registration by lincolnblog

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									    Lincoln High School Water Polo Club 2011 Athlete Info
(please complete and return to Anita Stark, 4625 SW 53rd Avenue Portland,
              OR 97221 or scan and e-mail by August 15th)



Athlete’s Name: _______________________ Year in School: __________

Address: ______________________________________________________

_____________________________________________________________


Parent Name: __________________________________________________

Home Phone: _________________________________________________

Parent Cell Phone: ______________________________________________

Athlete’s Cell Phone: ___________________________________________

Parent e-mail: _________________________________________________

Athlete’s e-mail: _______________________________________________

Emergency Contact Name: _______________________________________

Emergency Contact Phone: _______________________________________

Insurance Policy Name and Number: _______________________________

Any Medical Conditions:
   Lincoln High School Water Polo Club 2010 Waiver
(please complete and return to Anita Stark, 4625 SW 53rd Avenue Portland,
              OR 97221 or scan and e-mail by August 15th)

This waiver is for a Chartered Club Team that is registered with USA
Water Polo and is affiliated with, but not sponsored by Lincoln High
School/Portland School District.

As a parent(s) or legal guardian(s) of ______________________________

or as a student member of the Lincoln High School Water Polo Team, I/we,

undersigned, hereby release and agree to defend and hold harmless School

District No. 1, Multnomah County, Oregon (district), its officers, agents,

employees and their assigns and the team coaches and volunteer parents

from any claims from any person, entity or estate, in any forum that may

arise against them by reason of property loss or injury and/or death resulting

from any cause including but not limited to the student or other students

having failed to properly carry out instructions from the club leadership.



Dated this __________ of ________________________. 2010.

Signature of Parent or Legal Guardian _____________________________

Printed Name of Legal Guardian __________________________________

Signature of Athlete____________________________________________

Printed Name of Athlete_________________________________________

								
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