PLEASE PRINT
COUNCIL BLUFFS SWIM CLUB
2011-12 REGISTRATION
NAME:_________________________________________________ DATE OF BIRTH:____/____/____
LAST FIRST MI
ADDRESS: _____________________________________________ AGE: _________ SEX:________
CITY: ___________________________________________ STATE: _________ ZIP: ____________
PARENTS’ NAMES: ___________________________________________________________
HOME PHONE: __________________________ WORK PHONE: _________________________
_____MOTHER OR _____FATHER
E-MAIL ADDRESS: _____________________________________
EMERGENCY CONTACT PERSON: ___________________________________________________
PHONE # ____________________________ RELATIONSHIP:_____________________________
REGISTRATION FEE: ONE TIME CHARGE PER SEASON: $65.00 _______
THIS INCLUDES USA SWIM REGISTRATION FEES
GROUP FEES
_____BLUE GROUP $45.00 PER MONTH _______
Monday thru Thursday 5:30-6:15 PM
_____GOLD GROUP I, II, III $55.00 PER MONTH _______
Monday thru Thursday 5:30-6:45 PM
_____SENIORS $70.00 PER MONTH _______
Monday thru Friday 3:30-5:30 PM
Saturday 8:00-10:00 AM
TOTAL FEES _______
I have reviewed the club’s policies pertaining to monthly fees, swim meet fees and fundraising and I understand
the financial responsibilities.
PARENT SIGNATURE_______________________________________________DATE: ___________
CHECK#_____________________ AMOUNT:__________________
CBSCregistration11-12