Summer Registration Form 2018
Please complete this form to register for the Viper Pigeon Summer Program.  Please be sure to select the correct pool location and program.
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Athlete Name: *
Date of Birth *
MM
/
DD
/
YYYY
Which pool will you be participating at? *
Which program will you be participating in? *
Current or Future High School
Gender *
Parent Name(s) *
Phone Number *
Alternate Phone Number
E-mail(s) *
seperate multiple e-mails with commas
Emergency Contact
Name and number
Medical Information
I hereby authorize the directors of the West Houston Water Polo Club to act according to their best judgment in any emergency requiring medical attention.  I know of no medical, mental, or physical problems, which might affect my MINOR CHILD’s ability to safely participate in this program others then the ones listed above.  I will be responsible for any medical and/or other charges in connection with my MINOR CHILD’s attendance at practices or tournaments.  I hereby agree to save, indemnify and hold harmless the West Houston Water Polo Club staff, its agents, employees, and sponsors against any and all liability, claims, or demands for damages arising from injuries, illness, or lost or stolen property sustained by my MINOR CHILD during participation with this program. *
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