2019-2020 Optima Synchro Registration Form
Please submit this registration form and mail payment by Monday September 16th or pay online now to confirm your spot on the team.

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Swimmer's Last Name *
First Name *
Date of Birth *
MM
/
DD
/
YYYY
Street address *
City *
State *
Zip code *
Home phone # *
Parent e-mail (primary) *
Parent e-mail (secondary)
Swimmer's e-mail (optional)
if you would like them to be included on team communcations
Mother's full name *
Mother's cell # *
Mother's work phone
Father's full name *
Father's cell # *
Father's work phone
In the event of practice cancellation or change, coaches may provide text updates/notification. *
Please check cell number(s) to be used for text communication.
Required
I authorize Optima Synchro to obtain, store, and/or use (without payment) any photographs, slides, and/or videotapes of my child for public relations, marketing/advertising, and/or internal training purposes. *
Required
If yes, please initial below.
Emergency Information
Emergency contact (other than a parent/guardian) *
First & last name
Phone # *
Relationship to child
Child's physician *
Physician phone # *
Child's dentist *
Dentist phone # *
Insurance Company *
Insurance ID or policy # *
Health history
List any chronic conditions, operations, injuries or medications:
List any dietary restrictions, allergies, reactions and treatment:
Is there documentation of a physical exam, immunization record, and lead screening on file at your child's school? *
Required
If Yes, please inital below:
Emergency Authorization
I hereby give permission for the coaches of Optima Synchro to provide first aid treatment to my child (named above) when necessary.  In the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive emergency medical treatment.  I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted.  I understand that Optima Synchro personnel will make every effort to contact me regarding any emergency involving my child.

Parent/guardian signature *
Full name
Date *
MM
/
DD
/
YYYY
Payment
Registration and payment are due Моnday, September 16th.*
For your convenience, you may pay via the PayPal button on the Parent Page.
- or -
If you prefer to mail payment or pay in full, please make check payable to Optima Aquatics and mail to:
Svetlana Malinovskaya, 168 River Road #317, Andover, MA  01810.
*Please note that registration is complete once payment has been received.
Please select your payment option below: *
Required
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