This is the Team Travel Release Form.   Wac does not allow the Club Staff to be involved in Massage Therapy, Mental Health Care, or unrelated adult Lodging or Transportation.   If we are on a Team Travel Trip, the Parent and Swimmer must fill out the attached form.

WAC:  MEDICAL INFORMATION AND EMERGENCY RELEASE

(One per swimmer)

Swimmer’s Name:  __________________________________________________

In the space provided below, list any pertinent health or medical information and instructions or special problems (allergies, tetanus booster dates, drug allergies, asthma, prescriptions, etc.)

____________________________________________________________________________________

____________________________________________________________________________________

Aside from yourselves (the parents/guardian of the swimmer) please indicate who you would like the

coaches to contact should there be an emergency involving your child.

Name: _______________________________       Contact Info:  _________________________________

Swimmer’s Doctor:  ____________________________________   Phone:  _______________________

Swimmer’s Dentist:  ____________________________________   Phone:  _______________________

I (we) hereby give our permission for _________________________ to practice with and participate in swim meets with the Williamsburg Aquatic Club.  Although I expect all reasonable safety procedures to be followed, I will not hold the Coaches of WAC nor any chaperone or volunteer working with the group personally liable for any accident which may occur.

In case of minor emergency (cuts, scratches, headaches, etc), I (we) give permission to the coaches or chaperones to treat these as they deem necessary.  In the event of a more serious emergency, I give permission for it to be handled in the best manner as determined by the chaperones or coaches of WAC until I am able to be contacted.

TO THE ATTENDING PHYSICIAN OR HOSPITAL:

Permission is hereby granted for you at the discretion of the coaches or chaperones of WAC to perform care that is necessary for the welfare of my child until such time as you are able to reach me personally.

INSURANCE INFORMATION:  (Must be complete)

Subscriber’s Name:  ____________________________________________________

Insurance Company:  ___________________________________________________

ID#: _________________________________________________________________

Group #:  _____________________________________________________________

Insurance Coverage (i.e. medical, dental):  ___________________________________

Insurance Authorization phone number:  _____________________________________

______________________________________________     ________________________________

Parent Signature