Membership Registration Form
Member Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
USA Triathlon Member # (if applicable)
Note. If you are a current USAT member, please provide your member # here. We need this number for insurance purposes.
Emergency Contact
Name of Emergency Contact
*
First Name
Last Name
Phone Number of Emergency Contact
*
Please enter a valid phone number.
Age Verification
Are you at least 18 years of age?
*
Yes
No
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Minor Release Form
This section MUST be complete, if the applying member is under 18 years old.
Name of Parent/Guardian
First Name
Last Name
Email of Parent/Guardian
example@example.com
Contact information of Parent/Guardian
Same as above
Different from above
Address of Parent/Guardian (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Parent/Guardian (if different from above)
Please enter a valid phone number.
Minor Release
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Releases & Waivers
Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement, and Name and Likeness Release
Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement, and Name and Likeness Release
*
Signature (For minors, the legal guardian/parent MUST sign this form.)
*
Date
*
-
Month
-
Day
Year
Date
Freewill Donation through PayPal
While club membership is free, we welcome freewill donations. Our club is a not for profit club, and has several expenses during the year, e.g., USAT Club Membership, USAT Club Insurances, Support for Club Events, domain name for our web presence (https://headwaterstri.org/), etc. If you want to make a donation, please visit http://headwaterstri.org/donate AFTER you submitted this form.
Submit
Submit
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