Try It Out Registration and Waiver (K-W Water Polo)

Print Try It Out Registration and Waiver

KW Water Polo Club
TRY IT OUT REGISTRATION and WAIVER

Membership Information

This section allows us to identify new members and the club member who recruited them to the club.

Membership Status^*
Try It Out
How did you hear about us?
Recruited by Member. Please also note name of member below.
Kitchener Activity Guide
Waterloo Activity Guide
Handout, Flyer or Bulletin Board
Internet Search
Instagram
Facebook
Twitter
519 Sports Online
Radio Ad
Lawn Sign
Community Event
Other
Check All That Apply
If someone invited you out, tell us who.

Athlete's Basic Information

Athlete's First Name^*
Athlete's Last Name^*
Athlete's Gender Identity^*

Athlete's Date of Birth^*

Open the calendar popup.

Primary Email Contact^*

Email address monitored most frequently for this Athlete - Example: [email protected]. A copy of your waiver will be sent to this address for you to print and bring to tryout.

Athlete's Contact Information

Athlete's Street Address^*
Athlete's City^*
Athlete's Postal Code^*
Athlete's Home Phone^*

Example: ###-###-####

Athlete's Medical Information

Athlete's Health Card Number^*
Previous history of concussions^*
YesNo
Fainting episodes during exercise^*
YesNo
Seizures and/or Epilepsy^*
YesNo
Trouble breathing during exercise^*
YesNo
Heart condition^*
YesNo
Has any health problem that would interfere with participation on a water polo team^*
YesNo
Has had an illness that lasted more than a week and required medical attention in the past year^*
YesNo
Has had injuries requiring medical attention in the past year^*
YesNo
Has been admitted to hospital in the last year^*
YesNo
Has had surgery in the past year^*
YesNo
Presently injured^*
YesNo
Please give details if you answered "Yes" to any of the above.

Medical Acknowledgement

I/WE verify that the medical information provided on the application is correct and complete.^*

Parent/Guardian Contact Information

Parent/Guardian Full Name^*
Parent/Guardian Relationship To Athlete^*
Parent/Guardian Phone Number^*

Example: ###-###-####
Parent/Guardian Email Address^*

Example: [email protected]

Emergency Contact Information

Name of Emergency Contact If Parent/Guardian Not Available^*
Relationship of Emergency Contact to Athlete^*
Phone Number of Emergency Contact^*

Example: ###-###-####
Second Phone Number for Emergency Backup

Example: ###-###-####

Notice of Warning

There is a potential risk for injury involved in training and participating in the sport of water polo. Ontario Water Polo Association (OWP), and its member clubs, have tried to create a safe and controlled environment for participation. OWP has established rules for participation and conduct, on and about the playing area, that must be followed. Some hazards which may lead to catastrophic situations are: slips on the pool deck or surrounding area, chlorine leaks, ball injuries and personal body contact injuries, etc. In part consideration of the KW Water Polo Club permitting me/my child to take part in the practices and other activities of the Club, I hereby release the Club and its employees, agents and volunteers from any and all damages sustained in consequence of loss, injury or damage to any person or property and from any or all actions, causes of action, claims and demands of any nature arising directly or indirectly from my/my child’s participation in water polo. By signing this document I agree to and will abide to all OWP policies. If I am a parent/guardian of a minor, I provide consent for my minor child to participate with OWP.

I have read and understand the Notice of Warning^*
Acknowledgement

I/WE acknowledge that I/WE have read and understand and agree to this waiver and release of liability and authorization in favour of the KW Water Polo Club, its employees, agents and volunteers. ^*

Human Validation

Check The Box ^*