SHSC Emergency Form – Somerset Hills Swim Club

Family Name

Home Phone *

Cell Phone *

Address *

Address

City

State/Province

Zip/Postal

Email *

Family Physician *

Physician Phone *

Hospital Preference

Please list all family members and any Medical Information

Name 1 *

Birthdate 1 *

Allergies 1 *

Medical Conditions 1 *

Name 2

Birthdate 2

Allergies 2

Medical Conditions 2

Name 3

Birthdate 3

Allergies 3

Medical Conditions 3

Name 4

Birthdate 4

Allergies 4

Medical Conditions 4

Name 5

Birthdate 5

Allergies 5

Medical Conditions 5

Name 6

Birthdate 6

Allergies 6

Medical Conditions 6

Emergency Contacts

Emergency Contact 1 Name

Emergency Contact 1 Relationship

Emergency Contact 1 Cell Phone

Emergency Contact 1 Home Phone

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Cell Phone

Emergency Contact 2 Home Phone

Emergency Contact 3 Name

Emergency Contact 3 Relationship

Emergency Contact 3 Cell Phone

Emergency Contact 3 Home Phone

Our Family has reviewed the Pool Rules and By Laws of Somerset Hills Swim Club and all family members agree to abide by all Rules and By Laws

Signature of Adult Family Member *

Clear

Date *

Phone