Traverse City Breakers
Swim Club


P.O. Box 302 Traverse City, Michigan 49685-0302

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Breakers Registration

I, the undersigned parent/guardian would like to enroll the following child in the Traverse City Swim Club Summer 2008 Breakers program:

Child's Name:  
Birthdate:
Age:
M/F:
Mother:
Father:
Address:
Home Phone:
Work Phone:
Cell Phone:
E-Mail:
Emergency Contact w/phone:
Physician:
Physician Address:
Physician Phone:
Health Insurance Information:
   Parents Electronic Signature:
Comments/Requests:

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