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Learn to Swim Welcome Packet
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Gold Medal Swim Club Medical Release
Gold Medal Swim Club Medical Release
Form filled out Date and time
Personal Information
First Name
*
Middle Name(s)
Last Name
*
Swimmer's Age
*
Birthday
*
Month
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Street Address
*
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*
State
*
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ZIP Code
*
Phone Number
*
Email Address
*
Any Allergies?
Any medical conditions of which the coach should be aware?
List any medications, including supplements, the swimmer is taking:
Mother's Name
Mother's Phone Number
*
Father's Name
Father's Phone Number
*
Emergency Contact
First Name
*
Last Name
*
Relation
*
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Mother
Father
Sibling
Child
Spouse
Significant Other
Grandparent
Aunt
Uncle
Roommate
Other
Phone Number
*
Medical Release
*
I agree to the medical release.
I hereby give my permission for any and all medical attention to be administered to my child, in the event of an accident, injury or sickness under the direction of the person listed below until such time as I may be contacted. This release is effective until revoked by me. I also hereby assume the responsibility for payment of any such medical treatment. In case I cannot be reached, any of the following are designated to approve such treatment:
Any Member of the Gold Medal Swim Club Coaching Staff or person designated by the Coaching Staff.
Name of Insurance Company
Subscriber's Name
Policy Number
Group Number
Swimmer's Primary Care Physician
Primary Care Physician's Phone
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
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