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

I will follow the rule and regulations of the race event.I am in good shape, health, and condition.I don't have any medical condition or medical history that will be affected if I participate in this event.I acknowledge that this race requires physical activity and there are possible risks and danger.I release the race event organizers for any responsibility in case of an accident, illness, or injury.I allow taking my photos or the procedure images that can be used for the event portfolio or advertising.I confirm that all information in this registration form is accurate and true.

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

Terms/ Waiver/ Release