Packanack Lake Swim Club (PLSC)

Packanack Lake Swim Club (PLSC)

2023 Registration Form
Full Name of Mother/Guardian

First NameLast Name
Mother/Guardian's Main Contact Number
Please enter a valid phone number.
Mother/Guardian's Email
example@example.com
Full Name of Father

First NameLast Name
Father's Main Contact Number
Please enter a valid phone number.
Father's Email
example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact (other than parent/guardian)

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Swimmer 1
Swimmer 1 Name

First NameLast Name
Birth Date
Age on June 1, 2023
Senior Swimmer?

Age 15 through 18 and attending high school
Allergies/chronic illnesses or other concerns

Swimmer 2
Swimmer 2 Name

First NameLast Name
Birth Date
Age on June 1, 2023
Senior Swimmer?

Age 15 through 18 and attending high school
Allergies/chronic illnesses or other concerns

Swimmer 3
Swimmer 3 Name

First NameLast Name
Birth Date
Age on June 1, 2023
Senior Swimmer?

Age 15 through 18 and attending high school
Allergies/chronic illnesses or other concerns

Swimmer 4
Swimmer 4 Name

First NameLast Name
Birth Date
Age on June 1, 2023
Senior Swimmer?

Age 15 through 18 and attending high school
Allergies/chronic illnesses or other concerns

Doctor's Name or Office
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/guardian hereby grants to the Packanack Lake Swim Club, its agents, servants or employees, permission to take any and all steps it may deem necessary to protect said child/children in case of a medical emergency and does release said Club, its agents, servants or employees, from any and all liability with respect thereto.

PAYMENT

Dues are due by Wednesday, June 1, 2023.

Payable by check to: PLSC and return to:

Alison Knapp
95 Lake Dr W
Wayne, NJ 07470

or VENMO: Kathleen Syron-Briceno (@packanackswim)
Number of swimmers that are 14 years old and under on June 1, 2023
Number of swimmers that are 15 to 18 years old on June 1, 2023
Total Cost ($):

Guidelines and Waiver

On behalf of myself and my minor child/my minor children, I represent, understand, and agree as follows:

1. I represent that I have obtained PLCA beach badges for all individuals who may be involved with my child’s/my children’s participation in any PLSC activities in 2023. I represent that I received and reviewed the PLCA Beach Guidelines when I obtained these PLCA beach badges. I understand and agree, on behalf of myself and my minor child/my minor children, that the PLCA Beach Guidelines are applicable to all PLSC activities in 2023.

2. I represent that when I was issued these PLCA beach badges, I received, reviewed, and signed, on behalf of myself and my minor child/my minor children, the PLCA’s Waiver of Liability Relating to Coronavirus/COVID-19 (the “PLCA Waiver”). I understand and agree, on behalf of myself and my minor child/my minor children, that the PLCA Waiver applies to all PLSC activities in 2023.

3. I understand that the PLSC will establish additional guidelines applicable to PLSC activities in 2023.

4. I agree, on behalf of myself and my minor child/my minor children, to follow all PLCA Beach Guidelines and all PLCS guidelines when participating in PLSC activities in 2023. I understand and agree that a failure to follow applicable guidelines may result in my child/my children being asked to leave a daily PLSC activity and repeated failures to follow applicable guidelines may result in my child/my children being prohibited from participating in further PLSC activities in 2023.

5. I grant PLSC the right to photograph or video my child. I agree to the use of photographs or videos of my child for any lawful purpose, including such purposes as publicity, illustration, advertising, and web content.
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