Children's Information

Child's Name  Birthday Boy Girl
Child's Name  Birthday Boy Girl
Child's Name  Birthday Boy Girl
Child's Name  Birthday Boy Girl

Parent Information

Email               

  First Name         Last Name     

Spouse or Other Guardian Information:

  First Name          Last Name  

Address           
Address cont'd 

City               State    Zip

Home Phone     Work Phone

Emergency Contact and Number 

Medical Release & Other Information
for
and Family

 Please list any other medical problems such as Allergies / Medications, Other info.

Physician's Name      Physician's Number 

Insurance Company Name and Policy Number
Insurance Company Policy Number

I, ,agree to release Youth Swimming, Inc., Walton Waves, Inc. , Youth Athletic Recreation Company, Inc., & Staff, Bluesprings Sports Ranch & Staff from any responsibility for property damage, illness, or injury incurred by my child(ren), at Bluesprings. I agree to allow Walton Waves Swimming Staff, or another authority to administer First Aide for my child(ren), if necessary. I, the undersigned, will be responsible for any & all costs of medical attention and/or treatment.  I, hereby give permission for any and all medical attention to be administered to my child, in the event of accident, injury or sickness, under the direction of the person(s) below, until such time as I may be contacted. I also assume responsibility for the payment of any such treatment. Youth Swimming, Inc., Walton Waves, Inc. , Youth Athletic Recreation Company, Inc., & Staff, Bluesprings Sports Ranch & Staff from will not be held responsible for property damage, illness, or injury incurred by my child at Bluesprings.  
     In case I cannot be reached, any of the following persons are designated to act on my behalf: 
* Coach * Assistant Coach * Designee of the Walton Waves/Youth Swim Team

Signed _____________________________________Date __________________

Please make checks payable to : Crystal Aquatics
You can mail registration form to:
Crystal Aquatics Swim Lessons
1810 Kristins Way
Loganville, Georgia 30052
If you have any further questions please call (770) 466-8353