Delaware Riptide Swimmer Registration Form
Swimmer and Parent Information

  1. Full Name      2. Date of Birth     3. Age 
  4. Address     5. City    6. State
  7. Email    8. Phone  
  9. Years of Competitive swimming    10. School/District    11.Grade
  12.Fathers Name   13. Cell/Work Phone
  14.Mothers Name     15. Cell/Work Phone 
  16.Health Insurance Company    17. Policy #
  18.Emergency Contact    19. Emergency Phone
  20.Physician    21.Phone 
  22.Please check boxes that apply   22A. Allergies 22B. Diabetes
  22C.Heart Diseas  22D. Hypertension/High BP   22E. Retinal Issues   22F. Seizures
  22G. Lung Disease /Asthma   22H.Recent Surgeries
  22I. Sensory/Physical Disabilities
  22J. Other
   23. If you checked any boxes in #22 please explain
 

Please advise us if any changes Thank You!
Note: For those under 18 who have seizures that are not currently controlled by medication, a parent or guardian should be present during activities.

Riptide Fundraising Agreement 

I the parent of above named swimmer understand that in order to swim with Delaware Riptide Aquatics we are required to volunteer at one Delaware Interscholastic Athletic Association championship game and sell t-shirts for Riptide. A $50.00 retainer fee is required for each family. I understand that these funds will be forfeited if I or my representative fail to participate in a fundraising event. I understand that it is my responsibility to find someone to cover for me if I am unable to attend any event I have signed up for. I understand that after successful completion of a DIAA t-shirt event monies will be returned to me in check form via US mail.  Please choose one event and one alternate event to participate in. We will try to honor first choices.

 Spring 2008     "Outdoor Track": May 16 or 17   "Girls Lacrosse": May 24       "Boys Lacrosse": May 24
 
Fall 2008          "Cross Country" Nov             "Football"  Nov/Dec 
                         "Field Hockey"  Nov              "Boys Soccer"  Nov

Winter 2009     "Indoor Track"- Feb 
                         "Girls Volleyball Semi"   Feb  "Girls Volleyball Finals"
                         "Boys Basketball Qtr final"  Late Feb    "Girls Basketball Qtr final"
                         "Boys Basketball Semi"                          "Girls Basketball Semi"
                         "Boys Basketball Finals"  Early March   "Girls Basketball Finals"  Early March
                           

  24. Please Type in your First Choice of Event    
  25.Please Type in your Second  Choice of Event
 

Participation Consent/Waiver/Hold Harmless Agreement

- I hereby acknowledge that the above named swimmer will participate fully in the Delaware Riptide Aquatics Swim Team (Riptide) as specified on the registration form.
- In the event that an illness, accident, or loss of consciousness should occur and a parent/guardian is not present, I give coaching staff, and/or other facility personnel of Riptide, St. Andrew’s School, and/or other facility used by Riptide permission to seek emergency treatment as deemed appropriate.
- I acknowledge that the nature of the activity may expose Participant to hazards or risks that may result in Participant’s illness, personal injury, or death and I understand and the consequences of such hazards and risks.
- I hereby accept all risk to Participant’s health and of his/her injury or death that may result from participation and I hereby release Delaware Riptide Aquatics, Inc., St. Andrew’s School, The Clubhouse of Frog Hollow, their governing boards, officers, employees, and representatives from any and all liability to Participant, Participant’s personal representatives, estates, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to Participant’s property and for any and all illness or injury to Participant’s person, including his/her death, that may result from or occur during Participant’s participation in the Activity, whether caused by negligence of the Institutions and their governing boards, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless Institutions and their governing boards, officers, employees, or representatives, or otherwise from liability for the injury or death of any person(s) and damage to property that may result from Participant’s negligent or intentional act or omission while participating in the described Activity.
- I hereby release Coaches, Staff, and Board Members of Riptide, St. Andrew’s School, or any other facility used by Delaware Riptide from any and all claims which may hereafter arise from any alleged breach of any alleged warranty, expressed or implied, concerning Delaware Riptide Aquatics Programs and specifically the program stated on the registration form, and from any and all claims arising out of any injury or illness which I may suffer during or as a result of this program.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR PARTICIPANT’S INJURY OR DEATH OR DAMAGE TO PARTICIPANT’S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT’S NEGLIGENT OR INTENTIONAL ACT OR OMISSION.  

 Your Initials and date at the bottom of the form will complete the form and then hit Submit button  It will create a copy you can choose to print for your records

Signature of Parent/Guardian - I am the Parent/Legal Guardian of the above named Participant who is under 18 years of age and I am fully competent to sign this Agreement. I give permission for the Participant to participate fully in the above–referenced Activity.
I have read, understood and signed up for a Shirt sales event to fulfill the Riptide Fundraising Agreement.
I have read, understood and initialed and dated the boxes below to acknowledge consent of participation and that all the information is correct to the best of my knowledge.
 Cost: $120.00 Riptide dues per swimmer $55.00 Mandatory Insurance per swimmer
 $50.00 Fundraiser retainer per family* *this will be returned after selling t-shirts at one DIAA event
Please mail your Registration fees to     Delaware Riptide  P.  O.  Box  48 Middletown, De 19709

Signature  (please type your initials in the box: min 2 max 4 letters)    Date i.e.1/12/08