SPRINGWOOD SWIM CLUB P. O. Box 21394 4554 Concord Blvd. Concord, CA  94521

MEMBERSHIP REGISTRATION & EMERGENCY FORM

Club Phone#:  925-798-3493 Website: Http://www.springwoodswim.com

Family Name:

Home Phone:

E-mail:

How do you wish to be contacted regarding Club activities, updates, newsletters, billing statements?

E-MAIL

Adult Name(s):

Cell Phone #:

Work Phone #:

Home Address:

Child's Name:

Birthdate:

Child's Name:

Birthdate:

Child's Name:

Birthdate:

Birthdate:

Doctor's Name:

Medical Insurance Carrier / Group # / ID#:

Dentist's Name:

In case of emergency (if members unavailable) please notify:

Emerg. Contact:

Medical conditions/information that we should be aware of:

How did you hear about Springwood?  Is there a SPW member, we should thank for recruiting you?

Please mail all papers & monies to: Springwood Swim Club. P. O. Box 21394, Concord, CA  94521 OR GIVE PAPERWORK TO GATEKEEPER AT THE CLUB. Please read and sign 2nd pape below and attach to registration form.

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