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Coronado Aquatics Club
Post Office 181070
Coronado, CA. 92178
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CORONADO AQUATICS CLUB
Athlete Registration Form
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Please complete (PRINT or TYPE) and return with your payment
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Payment Method: Direct by Check ___ Debit/Credit Card Online ___
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Athlete’s Name: ______________________________
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Parent’s/ Guardian’s name completing form (if athlete under 18 years): _____________________
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Address: ____________________________________
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City / Zip: ____________________________________
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Phone Number: (____)__________________________
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E-mail Address: _______________________________
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Current School Attending: _______________________
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Grade in School: __________
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Gender: Male Female
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Date of Birth: _____________
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Current Age: _________
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USWP Membership Number: _____________
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Expiration Date: _______________
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USS Membership Number: _______________
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Expiration Date: _______________
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Emergency Contact: ________________________________________________________
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Emergency Contact Phone Number: (____)__________________________
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For Administrative Use Only
Fee Received (Payable to Coronado Aquatics Club) $__________
Date Received __________
USWP New (Payable to USWP) $_________ Renewal (Payable to USWP) $_________
USS New (Payable to USS) $_________ Renewal (Payable to USS) $_________
Forms: Registration ___ Code of Conduct ___ Medical Release ___
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Mail All Forms and Payments to the Above Address
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