2019 LAKE MANASSAS SWIM TEAM REGISTRATION

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PLEASE FILL OUT ONE FORM PER SWIMMER

Email *

SWIMMER LAST NAME *

SWIMMER FIRST NAME *

DATE OF BIRTH *

YYYY

AGE *

Gender *

HOME ADDRESS *

PHONE NUMBER *

PARENT(S) NAME(S) *

Email Address (multiple addresses accepted)

LAKE MANASSAS RESIDENT *

If above answer is no, please provide the name of the Lake Manassas resident sponsor *

PHOTO RELEASE: I give permission for my child's picture to be used on the team website and/or in local team promotional publications or advertisements. *

DISCLAIMER: I agree to abide by all facility rules and regulations. I represent that I have no life threatening conditions. I know that swimming in water activities involves a degree of risk. By participating in the program, I accept all risks associated with the use of the facility and participation in the program. If the participant is a minor, I accept risk on his/her behalf as their parent/legal guardian. I hereby release Lake Manassas Swim Team, its employees, pool committee members and independent contractors from any and all damages for personal injuries arising in any way from the use of the facility or participation is a minor, I execute this release on his/her behalf as his or her parent/legal guardian. *

FEE: check one *

PAYMENT - PLEASE MAKE PAYMENT ELECTRONICALLY USING ZELLE, EITHER THROUGH THE APP OR YOUR ONLINE BANKING

Send all payments to lmst.swim@gmail.com

https://www.zellepay.com/get-started

If you prefer to pay with a check or cash please drop off payment at The Baird's 7959 Valderrama Court, Gainesville, VA 20155

Send me a copy of my responses.

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