Registration 2022/2023 Membership for Athletes (K-W Water Polo)

Print Registration 2022/2023 Membership for Athletes

KW Water Polo Club
2022 - 2023 MEMBERSHIP APPLICATION

Membership Information

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

Membership Status^*
Returning MemberNew Member
New Members - 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
Other
Check All That Apply
New Members - If someone recruited you, tell us who we should thank.

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 membership application will be sent to this address.

Athlete's Contact Information

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

Example: ###-###-####
Athlete's Cell Phone

Example: ###-###-####
Athlete's Email Address

Athlete's email address will be added to the mailing list.

Athlete's Medical Information

Athlete's Health Card Number^*
Medication^*
YesNo
Allergies^*
YesNo
Previous history of concussions^*
YesNo
Fainting episodes during exercise^*
YesNo
Seizures and/or Epilepsy^*
YesNo
Wear glasses^*
YesNo
If Yes, are lenses shatterproof
YesNo
Wears contact lenses^*
YesNo
Wears dental appliance^*
YesNo
Hearing problem^*
YesNo
Asthma^*
YesNo
Trouble breathing during exercise^*
YesNo
Heart condition^*
YesNo
Diabetes - Type 1^*
YesNo
Diabetes - Type 2^*
YesNo
Wears a medical information bracelet, necklace or tattoo^*
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 agree that it is our responsibility to advise the club of any changes in the medical information as soon as possible. We understand that this information may be shared with club officials and volunteers who may from time to time be in a position of responsibility for our athlete. In the event of a medical emergency, and that no one can be contacted, Club management may arrange to take my child to the hospital or a physician if deemed necessary. I authorize the physician and nursing staff to undertake examination, investigation and necessary treatment of my child.^*

Parent/Guardian Contact Information

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

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

Example: [email protected]
Second Parent/Guardian Full Name
Second Parent/Guardian Relationship To Athlete
Second Parent/Guardian Phone Number

Example: ###-###-####
Second Parent/Guardian Email Address

Example: [email protected]
Third Parent/Guardian Full Name
Third Parent/Guardian Relationship To Athlete
Third Parent/Guardian Phone Number

Example: ###-###-####
Third Parent/Guardian Email Address

Example: [email protected]
Fourth Parent/Guardian Full Name
Fourth Parent/Guardian Relationship To Athlete
Fourth Parent/Guardian Phone Number

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

Financial Commitment

Team	Proposed 22/23 Membership	Tournament Fees Account	2022/2023 Fees	Payment Method	Total
9U Co-ed	$265	To be determined	$265/session**	Lump Sum	$265 Fall Session $265 Winter Session
11U Co-ed	$315	To be determined	$315/session**	Lump Sum	$315 Fall Session $315 Winter Session
13U Co-ed	$1245	$800	$1245	Lump Sum or 50/50 (Oct/Jan)	$2045
15U 17U 19U	$2045	$1000 (includes OPL and NCL fees)	$2045	Lump Sum or 50/50 (Oct/Jan)	$3045

**Jr Kraken 9U fees: $265/session, 11U fees: $315/session, 2 Sessions -Fall: Sept-Dec -Winter: Jan-Apr

Normally fees include both membership and the seeding of your tournament account for all forms of competition including tournaments, league days and National Competitive League (NCL) fees. There is a high likelihood that competitions will be allowed for this upcoming season. Should competition occur, please be aware that you are also financially accountable for these costs. Note that personal cost of travel, accommodation, food and incidentals are not included in any fees collected.

Under normal circumstances, it is important to note that the fees for competition are an estimate only. Actual competition fees will vary with some families receiving a refund and others being required to pay additional costs depending on the number of competitions their athlete participates in. This includes playing up for an older team.

Refer to the Tournament account page for additional information on how tournament fees are managed.

Payment options:

Payment in full by cheque made out to KW Water Polo Club. Give the cheque to the team manager for that respective age group. Please indicate player name on the cheque.
Installment payments will be made on the 15th of October and January. A VOID cheque must be provided either as an attachment in your electronic application, or sent to the Treasurer via the team manager for that respective age group. Please indicate player name on the cheque.
Refer to the Fee Assistance page if required.

I agree to to pay my annual membership fee in full. I further acknowledge that I am responsible for the fees associated with ALL tournaments my player attends.^*

Bingo Commitment

It is mandatory for each family to help at UP TO TWO Bingo sessions throughout the season for each athlete registered.

This year, signup will occur after registration once dates are known. Due to the significant time already invested by these volunteers: Board members, parent coaches, team managers and Bingo captain(s) are not required to volunteer for Bingo sessions.

Post-dated cheque(s), dated May 15, 2022, must be provided during the official registration period in the fall, in the amount of $500 for each athlete, as security for completing the Bingo sessions. It will not be cashed unless you do not complete your Bingo commitment by the last session in September 2022.

I agree to meet my Bingo commitment and will provide the required post-dated cheque(s)^*

Payment Information

I intend to pay my membership and tournament fees by^*
Payment in full by cheque
Installment payments on the 15th of October and December
You have the option of attaching a photograph of a VOID cheque here, if paying by pre-authorized payment.

Allowed extensions: .jpeg, .jpg, .png, gif, .pdf.
Maximum # Files: 1. Maximum File Size: 4MB.

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 of Policies and Guidelines

You should be aware and be prepared to follow the policies and guidelines outlined below. Review the policies and guidelines below and provide your acknowledgment.

Waterpolo Canada Code of Conduct
OWP PIPEDA Policy
KW Water Polo Club Policy
OWP Standards of Behaviour
KW Water Polo Club Code of Conduct
OWPA Referee Policy (for referees only)
CACE Code of Conduct and Ethics Code (for coaches only)
City of Waterloo Respectful Behaviour Policy
Conflict Resolution Policy
Concussion Policy
Code of Conduct, Standards of Behaviour and Conflict Resolution

We (parent and athlete) have reviewed , understand and will abide by the terms and conditions in the Water Polo Canada Code of Conduct, the OWP Standards of Behaviour, The City of Waterloo Respectful Behaviour Policy and the KW Water Polo Code of Conduct (including the Parent Code of Conduct and Change Room Policy) as found on the KW Water Polo web site. We will abide by the Conflict Resolution Policy and Procedures ^*
Personal Information Protection and Electronics Documents Act (“PIPEDA”)

I am aware of the OWP PIPEDA policy and give permission to KW Water Polo Club to enter required personal information on the KW Water Polo Club and Ontario Water Polo Association database for the purposes outlined in the KW Water Polo Club Policy, which I have read. ^*
Medical Situations and Concussion Protocol

I/WE have reviewed the Concussion Policy. In the event of a medical emergency, I authorize the Club, its employees, agents and volunteers to provide ANY medical first aid, which they deem reasonably necessary for me/my child in the event of my or his/her injury during the activities of the Club. I agree to reimburse the Club for all expenses, incurred thereby.^*
Photographic Waiver

Throughout the year player photos and videos may be used in several ways: to highlight players in newsletters, websites, bulletin board and/or year-end slide show, or to provide local press with photos for feature articles and promotional materials for the club. I/WE give permission to the KW Water Polo Club and its Board of Directors to have our player (named above) photographed and videotaped and such photographs and videos to be used as above. ^*
Consent to Electronic Communication

We (parent and athlete) are consenting to receive electronic communications related to the Club from KW Water Polo Club and its employees, agents and volunteers using the e-mail address that I have provided above or I will provide to the team manager to be added to the team email lists. We may withdraw our consent at any time by contacting [email protected]. ^*
COVID-19

As of Sept 1st, 2022 all COVID-19 safety precautions and restrictions have been lifted. However, please be advised, we will continue to follow Public Health Guidelines and specific facility requirements and may need to reimplement certain procedures if necessary.

I agree to the terms and conditions stated above^*
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. ^*
By submitting this document I/WE agree to and will abide by all KW Water Polo Club Policies. ^*

Human Validation

Check The Box ^*

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Tue May 30, 2023

Printed from kwwaterpolo.com on Tuesday, May 30, 2023 at 2:58 AM