Welcome to the Palisades Dive Team! 2019 Dive Team Registration - Partial Season Please complete the registration form below to pay for a partial season of Palisades Dive Team. Thank you! Diver InformationDiver Name* First Last Nickname First Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Age on June 1, 2019*The Montgomery County Dive League (MCDL) uses a diver's age as of June 1 to determine age groups for competition. Divers must be 18 or younger on June 1 to participate.Does Diver have any allergies?*YesNoIf yes, please explain:Does Diver carry an epipen?YesNoParent InformationParent 1 Name*Please provide the name and contact information for the parent completing this form. First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Parent 1 Email* Enter Email Confirm Email Parent 2 NamePlease provide the name and contact information for the second parent (optional). First Last Parent 2 Home Phone (if different than Parent 1)Parent 2 Cell PhoneParent 2 Email Enter Email Confirm Email Payment InformationPalisades Dive Team - Partial Season*This fee is for a diver who has already paid the "trial" insurance fee and will only participating in the dive team for part of the season. Price: $100.00 Total $0.00 Liability WaiverI give permission for my child to participate in Palisades Dive Team Practice and to participate in Palisades Dive Team competitions. I give my permission for any supervisor, coach or other team administrator associated with the Palisades Dive Team to seek and give appropriate emergency medical attention for our child(ren) in the event of accident, injury, illness. I will be responsible for any and all costs associated with any necessary medical attention and/or treatment. By registering my child(ren) with the Palisades Dive Team, I agree to participate (or allow my child to participate) in the Palisades Dive Team, and hereby release Palisades Dive Team, Montgomery County Dive League, their directors, officers, agents, coaches, and employees from liability for any injury that might occur to myself (or to my child(ren) and family members) while participating in the Palisades Dive Team program, including travel to and from training sessions, dive meets or other scheduled team activities. I agree to indemnify and hold harmless the above mentioned organizations and/or individuals, their agents and/or employees, against any and all liability for personal injury, including injuries resulting in death to me, my child(ren) and/or other family members, or damage to my property, the property to my child(ren) and/or other family members, or both, while I (or my child(ren) or family members) participating in the Palisades Dive Team program. Acceptance of Liability Waiver* By selecting this box and signing below, I agree to the liability waiver terms as specified above. Parent Signature*To sign simply click in the box with your left mouse button and hold down to draw. Or on a mobile device, simply sign with your finger.Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name
