SMA Track and Field

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Information
Parent 1*

First NameLast Name
Phone Number*

Area CodePhone Number
Email (this will be the primary email address for communications)*
example@example.com
Parent 2

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com

Emergency Medical Release
In the event of an emergency, I give permission to transport my child/ward to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact the following person:
Emergency Contact Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Primary Care Physician
Preferred Hospital
Health Insurance Company*
Insurance Policy #/ Group #*
Please furnish medical information about your child/ward which may be pertinent to his or her participation in this activity.

Authorization and Consent
I consent to the participation of my child/ward in the above named activity. In consideration for my child/ward's participation, I agree to reimburse and indemnify Stella Maris Academy (understood to include the Diocese of Duluth, St. James Church, Cathedral of Our Lady Church and St. John’s the Evangelist Church) for all reasonable legal and court fees incurred by Stella Maris Academy in defending a lawsuit that I or my child/ward may bring against Stella Maris Academy which relates to the above named activities if Stella Maris Academy is found not legally liable by the courts and prevails in the lawsuit. If Stella Maris Academy is found liable for the injuries sustained by child/ward, this paragraph will not apply.

I certify that I have an understanding of this agreement and the risks and hazards associated with the activity described above that my child/ward will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of Stella Maris Academy to clarify any concerns or questions about the activity or this agreement that I may have had.

By signing and confirming below, I verify that all information on this enrollment form is accurate and complete.
Do you have any questions or concerns that you would like addressed immediately?
Signature*

Registration

Grade 6 Track Registration Fee$100.00

Enter coupon

Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

SMA Track and Field Team