Whitesburg Recreation Association Dive Team Registration Form
Diver(s) Information:
Name ______________________________ Birth ____________ Age _____ Sex ___
Last First Middle MM/DD/YY M/F
Name ______________________________ Birth ____________ Age _____ Sex ___
Last First Middle MM/DD/YY M/F
Name ______________________________ Birth ____________ Age _____ Sex ___
Last First Middle MM/DD/YY M/F
Parent Information:
Parents: ________________________________________________________________
Address: ________________________________________________________________
Street City State Zip
Home Phone: ______________________ Work Phone: _____________________
Cell Phone: ______________________ E-Mail Address: _____________________
Cell Phone: ______________________ E-Mail Address: _____________________
Medical Release:
Please list any medical problem or allergies that your child(ren) may have:
_______________________________________________________________________
_______________________________________________________________________
How do we need to treat the problem: ________________________________________
I give permission for my child(ren) to be treated in an emergency in the event I cannot be reached.
____________________________________________________ __________________
Signature Date
Emergency Numbers:
Name: _______________________________________ Phone: ___________________
Name: _______________________________________ Phone: ___________________
Doctor’s name: ________________________________ Phone: ___________________
Fees: Make checks payable to WRA.
1 Diver: $56 / 2 Divers: $87 / 3 or more Divers: $107
# Divers: ___________________ Total Due Divers: _________________
# Trophies (optional): $7.00 each Total Due Trophies: _________________
For official use:
Amount paid:_______________ Check #__________ Date:____________