2023 Tri-State OTC Camp Application

Application Deadline March 20, 2023

Athlete Information

Legal First Name*

Middle Name

Last Name*

Preferred First Name

Birth Date*

Age (on 4/27/2023)*

Gender*

Shirt Size*

Club*

Athlete Cell

Athlete E-Mail

Street Address*

City*

State*

Zip Code*

Medical Conditions

Please list your top six individual events, best times and dates achieved
No 50's other than Freestyle * No Duplicate events LC/SC

Parent/Guardian Information

Parent/Guardian 1 Name*

Parent/Guardian 1 Cell*

Parent/Guardian 1 E-Mail*

Parent/Guardian 2 Name

Parent/Guardian 2 Cell

Parent/Guardian 2 E-Mail

Emergency Information

Emergency Contact Name*

Emergency Contact Cell*

Emergency Contact E-Mail*

Comments/Questions

Swimmers selected will be required to pay a $175 fee.

Liability Waiver & Medical Release

By registering my child(ren) with the Allegheny Mountain Swimming Tri-State Coalition OTC Camp (TSCOTC), I agree to participate (or allow my child(ren) and family members to participate) at the TSCOTC, and hereby release Allegheny Mountain Swimming, its directors, officers, agents, coaches, and employees from liability for any injury that might occur to myself (or to my child(ren) and family members) while participating in the TSCOTC, including travel to and from training sessions, swim meets or other scheduled team activities. I agree to indemnify and hold harmless the above mentioned organizations and/or individuals, their agents and/or employees, against any and all liability for personal injury, including injuries resulting in death to me, my child(ren) and/or other family members, or damage to my property, the property to my child(ren) and/or other family members, or both, while I (or my child(ren) or family members) participating in the Allegheny Mountain Swimming program.*

I certify that I am the parent or legal guardian for my child(ren). I hereby give my permission for any supervisor, coach or other team administrator associated with the Allegheny Mountain Swimming to seek and give appropriate medical attention for our child(ren) in the event of accident, injury, illness. I will be responsible for any and all costs associated with any necessary medical attention and/or treatment. I hereby waive, release and forever discharge Allegheny Mountain Swimming and associated supervisor, coach or other team administrator from all rights and claims for damages, injury, loss to person or property which may be sustained or occur during participation in Allegheny Mountain Swimming activities, whether or not damages or loss is due to negligence. I hereby acknowledge that my children is (are) physically fit and capable of participation in all Swim Team activities.*