Swimming Race Registration Form

Location: 1379 Horseshoe Lane, Philadelphia, PA, 19108
Race Dates: September 1, 2019 / September 4, 2019 / September 7, 2019
Time: 9:00AM - 3:00PM

Full Name

First NameLast Name

Age

Date of Birth

Date

Gender

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Person

First NameLast Name

Emergency Person Phone Number

Area CodePhone Number

Relationship to Emergency Contact Person

Payment Method

Registration Fee

10 years old and under$15.00

15 years old and under$25.00

1500 Meter$50.00

3500 Meter$60.00

Total $0.00

Participant's Signature

Date Signed

Date

Parent/Guardian Signature (If below 16 years old)

Date Signed

Date

Swimming Race Registration Form

Participant Information

Registration Payments

Registration Fee

Terms/ Waiver/ Release