Triathlon Swim Clinic Registration 

(to print, right-click this page and select print)

 

*Please circle the clinic you will be attending:

 
   
Please make checks payable to: Riptide Swim Team
 
Mail registration form and payment to:
Shandra Richardson
6712 Jackpin Place
Gainesville, VA 20155

 

 

SWIMMER(S) NAME

LAST NAME

 

 FIRST NAME
STREET

 

 CITY STATE ZIP
HOME PHONE

 

 E-MAIL ADDRESS
USAT Membership #:

 

 USAT Membership Expiration Date:
EMERGENCY CONTACT

 

 EMERGENCY PHONE
 $55.00 Swim clinic fee for USAT Members, $65.00 Swim clinic fee for non-USAT members (includes $10 one-day USAT license)

 

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Signature Date