STROKE CLINIC & SPRING/SUMMER TEAM REGISTRATION Stoic Aquatics Spring Clinic & Spring/Summer Team Registration Swimmer's InformationSwimmer's Name(Required) First Last Swimmer's Date of Birth(Required) MM slash DD slash YYYY Swimmer's Age (as of registration)(Required)Please select age56789101112131415161718192021Gender(Required) Male Female Other Swimmer's Grade(Required)Please select a grade123456789101112CollegeSwimmer's School District(Required)Swimmer's Contact Number(Required)Parent/Guardian InformationParent/Guardian Name (1)(Required) First Last Parent/Guardian Phone (1)(Required)Parent/Guardian Email (1)(Required) Parent/Guardian Address (1)(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Name (2) First Last Parent/Guardian Phone (2)Parent/Guardian Email (2) Is Parent/Guardian (2) Address same as Parent/Guardian Name (1) above? Yes No, I will enter different address Parent/Guardian Address (2) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact InformationEmergency Contact Name (1)(Required) First Last Emergency Contact Relationship (1)(Required)Emergency Contact Phone (1)(Required)Emergency Contact Name (2) First Last Emergency Contact Relationship (2)Emergency Contact Phone (2)Medical InformationPlease let us know if your swimmer has any allergies or takes any emergency medications. If none, please type NONE.(Required)Please let us know if there is any other information you would like us to know about your swimmer.PAYMENT PLANSIf you require a payment plan, please contact coach Greg by email at stoicaquatics.coachgreg@gmail.com for approval and plan details. There will be a $50.00 administrative fee added in to the total cost for all payment plans. Payment plans will be spread out over 4 payments and due by the 1st of every month.Please enter payment plan code if applicableRegistration Type SILVER-STROKE CLINIC ONLY (10 & Under)- $150.00 GOLD-STROKE CLINIC ONLY (11 & over)- $200.00 SILVER-SPRING/SUMMER TEAM (10 & under)- $200.00 GOLD-SPRING/SUMMER TEAM (11 & over)- $300.00 SILVER-COMBINED- STROKE CLINIC & SPRING/SUMMER TEAM (10 & under)- $350.00 GOLD-COMBINED- STROKE CLINIC & SPRING/SUMMER TEAM (11& OVER)- $500.00 Registration Type (Payment Plan) SILVER-STROKE CLINI ONLY (10 & under)- $50.00 GOLD-STROKE CLINIC ONLY (11 & OVER)- $132.00 SILVER-SPRING/SUMMER TEAM (10 & under)- $62.50 GOLD-SPRING/SUMMER TEAM (11 & over)- $87.50 SILVER-COMBINED- STROKE CLINIC & SPRING/SUMMER TEAM (10 & under)- $100.00 GOLD-COMBINED- STROKE CLINIC & SPRING/SUMMER TEAM- $137.50 Payment SectionCredit Card Cardholder Name Card Details
