Registration Form

Please print and complete the Registration Form and mail the Registration Form and the NKSL Waiver and payment to Janet Piccirillo at the address listed below:

2010 Beechwood Swim & Dive Team Registration

Note: Fees for 2010 remain at $55 per child for swimming or diving or $65 per child if they choose both. Fees include payment of insurance required by the NKSL, the end of season banquet (for the swimmer/diver) and one Cuda T-Shirt. Checks should be made out to: Beechwood Swim Team Boosters.

If you are interested in registering for the team, please complete the registration and insurance form below and return with payment to:

Janet Piccirillo

153 Lookout Farm Drive

Crestview Hills, KY 41017

Swimmers will not be permitted to participate without payment and a completed registration AND consent form.

Child's Name

Boy (B) or

Girl (G)

Age as of 5/31/10

Date of Birth

(m/dd/yy)

Swim (S) Dive (D) Both (B)

Fee

________________________________________________________________________

Please circle one:

Swimmer’s T-shirt size: YS YM YL YXL AS AM AL AXL

Additional swimmers/divers:

Swimmer’s T-shirt size: YS YM YL YXL AS AM AL AXL

Parent Information: (Note: we primarily communicate updates via email, so please provide)

Name: __________________________________________________________

Address: __________________________________________________________

City______________________________________ State______Zip____________

Home Phone: _____________________Work/Cell Phone:____________________

Please provide the e-mail address(es) to which you want all team related communications to be sent:

Email: ___________________________________________________________

Please return the registration AND the parental waiver & release form (on back side) together. A child cannot participate in any meets without the waiver & release form due to insurance purposes.

Remember: Please enclose the registration form, NKSL waiver/consent form, and your check.

NKSL Website