Edgewood Eels 2017 Swim Team Registration Form

CHILDREN MUST BE ABLE TO SWIM TWO LENGTHS OF THE POOL TO PARTICIPATE ON SWIM TEAM

Members Name*
Street Address*
City*
State*	PA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip*
Email Address*
Phone*
Swim Team Fees First Child - $ 125.00 Each Additional Child in Family - $25.00
Please enroll my child(ren)
First Child* $125.00
Date of birth*
Age*
Second Child $25.00
Date of birth
Age
Third Child $25.00
Date of birth
Age
Name on card*
Credit Card Number*
VIN number on from the back of card*
Exp. Date valid thru 10.31.2017*	01 02 03 04 05 06 07 08 09 10 11 12 2017 2018 2019 2020 2021 2022 2023
Card type*	Visa Master Card Discover American Express
Credit Card Billing Address (only if different than listed above)
Street Address
City
State	PA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip
As the credit card holder, I hereby authorize The Edgewood Club, to charge my credit card for the selected membership category and future fees verbally approved by me. *
I have read the WAIVER RELEASE OF RESPONSIBILITY (CLICK HERE) AND I HAVE FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE*