Swim Team Release Form for TPC Houston (Formerly Sweetwater Country Club)
A separate form was completed for SHRSL. This form is required for use of TPC Houston's facilities (Formerly Sweetwater Country Club). A separate form is required for each swimmer before they will be allowed to attend practice.
Today's Date
*
-
Month
-
Day
Year
Date
Guardian's Full Name
*
Relationship to Swimmer
The Swimmer's Full Name
*
Child's First Name
Child's Last Name
Age Group
Please Select
6 and Under
7-8 Yr Old
9-10 Yr Old
11-12 Yr Old
13-14 Yr Old
15 and Up, Open
Member Number (TPC Houston Member Number, or N/A)
Medical Form Information
Please list any allergies:
Immunizations (Yes or No):
Medical History (i.e. epilepsy, diabetes, etc.)
Preferred Hospital:
Family Physician:
Physician's Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company:
Insurance Company Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Policy Holder:
Policy Holder Date of Birth:
-
Month
-
Day
Year
Date
Policy Number or ID:
Group Number:
Emergency Contact #1 Name:
Emergency Contact #1 Relationship to Swimmer:
Emergency Contact #1 Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #1 Alternate Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 Name:
Emergency Contact #2 Relationship to Swimmer:
Emergency Contact #2 Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 Alternate Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #3 Name:
Emergency Contact #3 Relationship to Swimmer:
Emergency Contact #3 Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #3 Alternate Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Signature (please sign)
*
Email address
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