Greenbriar
Swim & Dive Teams 
Registration

Registration Fees:

- Dive team ONLY registration: 1 child - $125; 2 children - $175; 3 or more children - $200

- Swim Team ONLY registration 1 child -$175;  2 children - $275; 3 or more children - $350

- JOINT Swim & Dive registration: 1 child - $190; 2 children - $305; 3 or more children $395

Make checks Payable to Greenbriar Pool Club, Inc. and mail to: Greenbriar Pool Club, Inc., P.O. Box 220293, Chantilly, VA 20153-0293

Payment

Child 1

Name
Date of Birth
Sex Male Female
Activity Swim Dive Both

Child 2

Name
Date of Birth
Sex Male Female
Activity Swim Dive Both

Child 3

Name
Date of Birth
Sex Male Female
Activity Swim Dive Both

Child 4

Name
Date of Birth
Sex Male Female
Activity Swim Dive Both

Father's Contact Information

Name
Street Address
Address (cont.)
City
State
Zip Code
Country
Work Phone
Home Phone
Cell
E-mail
URL

Mother's Contact Information

Name
Street Address
Address (cont.)
City
State
Zip Code
Country
Work Phone
Cell
E-mail
URL

Doctor

Name
Work Phone

Emergency Contact

Name
Work Phone
Cell

Medical Conditions?

Medications: List or "NONE":


Check #
Date Mailed
Author information goes here.
Copyright © 1999 [OrganizationName]. All rights reserved.
Revised: April 22, 2010