Swim Test

Select Swimmer Group:*

Silver 1
Silver 2
Purple
White

Have you previously registered for a 2020-2021 session?*

No (I have not yet registered for any 2020-2021 sessions)
Yes (I have previously registered, and I wish to register for another session)

Have you previously registered for this season with USA Swim?*

No (I have not yet paid my USA Swim premium)
Yes (I have already registered for this swim season with USA Swim)

Choose the session you wish to register for:*

September 2020 ($225)
January 2021 ($225)
April-May 2021 ($150)

Returning White Group Registrants:

Swimmer's Name:*

First Middle Last

Parent or Legal Guardian's Name:*

First Middle Last

Swimmer Information

After submitting this form to confirm your application, you will be emailed a link to complete the USA Swimming 2021 Premium Athlete Registration Application. Please be sure to complete this form upon receipt.

After submitting this form to confirm your application, you will be emailed a link to complete the USA Swimming 2021 Flex Athlete Registration Application. Please be sure to complete this form upon receipt.

The Swimmer is a/an:*

Adult
Youth

T-Shirt Size*

Full Legal Name*

First Middle Last

Preferred Name

Age*

Birth Date*

Gender*

M
F

Cell Phone*

Address

Home Address*

Street Address Address Line 2 City State ZIP Code

Parent or Legal Guardian Information

Name*

First Middle Last

Cell Phone*

Cell Phone Carrier*

Email*

Name of Employer*

Business Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Name*

Relationship*

Phone*

Payment Details

IMPORTANT:

After submitting this form and paying the needed one-time fees, we will email you a second form to set up your monthly dues, as well as provide registration information for USA Swim (if you have not already done so). This second form must be filled out to finalize your Christus Swim registration. If you have any questions, please contact us.

CHRISTUS Louisiana Aquatic Club dues for Silver and Purple Groups are paid monthly. White Group is paid on a session by session basis. If dues are returned unpaid by your financial institution for any reason you will be assessed a $30 return fee in addition to the unpaid balance. Payments may be electronically transferred from your bank checking, savings account, or charged to your credit card. Any changes of payment method must reach the CHRISTUS Foundation office by the 20th day of the month preceding the next billing date. Direct charges are applied to your account on the 1 st business day of each month. It is the full responsibility of the account holder to notify the CHRISTUS Foundation office of any changes to accounts or debit cards. (Example: new expiration date or new account number)

I understand that after completing all registration forms, my CHRISTUS Louisiana Aquatic Club (monthly) dues will be drafted on the 1st day of each month from the payment option I have selected will be $80.00. I also understand that submitting this form will charge me a one-time $45.00 2020-2021 Swimmer Registration Fee, along with an one-time $80.00 USA Swim Premium fee

I understand that after completing all registration forms, my CHRISTUS Louisiana Aquatic Club (monthly) dues will be drafted on the 1st day of each month from the payment option I have selected will be $80.00. I also understand that submitting this form will charge me a one-time $45.00 2020-2021 Swimmer Registration Fee.

I understand that after completing all registration forms, my CHRISTUS Louisiana Aquatic Club (monthly) dues will be drafted on the 1st day of each month from the payment option I have selected will be $100.00. I also understand that submitting this form will charge me one-time $45.00 2020-2021 Swimmer Registration Fee, along with an one-time $80.00 USA Swim Premium fee

I understand that after completing all registration forms, my CHRISTUS Louisiana Aquatic Club (monthly) dues will be drafted on the 1st day of each month from the payment option I have selected will be $100.00. I also understand that submitting this form will charge me one-time $45.00 2020-2021 Swimmer Registration Fee.

I understand that after completing all registration forms, my CHRISTUS Louisiana Aquatic Club (monthly) dues will be drafted on the 1st day of each month from the payment option I have selected will be $120.00. I also understand that submitting this form will charge me a one-time $45.00 2020-2021 Swimmer Registration Fee, along with an one-time $80.00 USA Swim Premium fee

I understand that after completing all registration forms, my CHRISTUS Louisiana Aquatic Club (monthly) dues will be drafted on the 1st day of each month from the payment option I have selected will be $120.00. I also understand that submitting this form will charge me a one-time $45.00 2020-2021 Swimmer Registration Fee.

I understand that my CHRISTUS Louisiana Aquatic Club session dues from the payment option I have selected will be $20.00, plus $45.00 2020-2021 Swimmer Registration Fee and a $225.00 session fee.

I understand that my CHRISTUS Louisiana Aquatic Club session dues from the payment option I have selected will be $20.00, plus a $225.00 session fee.

I understand that my CHRISTUS Louisiana Aquatic Club session dues from the payment option I have selected will be $20.00, plus $45.00 2020-2021 Swimmer Registration Fee and a $225.00 session fee.

I understand that my CHRISTUS Louisiana Aquatic Club session dues from the payment option I have selected will be $20.00, plus a $225.00 session fee.

I understand that my CHRISTUS Louisiana Aquatic Club session dues from the payment option I have selected will be $20.00, plus $45.00 2020-2021 Swimmer Registration Fee and a $150.00 session fee.

I understand that my CHRISTUS Louisiana Aquatic Club session dues from the payment option I have selected will be $20.00, plus a $150.00 session fee.

*CANCELLATION POLICY for MONTHLY DRAFT: In order to cancel membership the account must have a zero balance. I understand that my written cancellation must reach the CHRISTUS Foundation office by the 15 th of the month preceding the effective date of cancellation. (Example: For a June 1 st cancellation the written cancellation must be received by May 15 th ).

CANCELLATION will not be accepted via telephone, fax, email, or any other electronic form of communication.

*ACCEPTANCE AGREEMENT, REFUND POLICY AND PAYMENT AGREEMENT: Upon acceptance of this Application by CHRISTUS Shreveport-Bossier Health System (CSBHS) the undersigned agrees to abide by all guidelines and policies of CSBHS, which are subject to change and which, in the opinion of the facility management, are deemed necessary and reasonable for the best interest of its members and CSBHS. This agreement is non-refundable and non-transferable. Memberships shall remain current. Any and all fees which are returned unpaid by your financial institution for two (2) consecutive months may be turned over to a collection agency for the total outstanding balance.

*CONSENT FOR RELEASE OF PHOTOGRAPH, VIDEO AND INTERVIEW: I hereby authorize approved staff members of CHRISTUS Shreveport-Bossier Health System and/or news media representatives to photograph, video, and/or interview the above named “Swimmer” for the purposes of publications, advertisements, video/audio recordings, and/or motion pictures. I understand and agree that CHRISTUS Shreveport-Bossier Health System will be held free and clear of any and all responsibility or claim for personal liability during the production of the aforementioned.

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2020-2021 Swim Team Application (REVISED 1/13/21) (JL TEST)

Returning White Group Registrants:

Swimmer Information

Address

Parent or Legal Guardian Information

Payment Details

IMPORTANT:

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