AYA Trojans Track Club - Registration Form

AYA Trojans Track Club - Registration Form
ATHLETE INFORMATION
Athlete Name*

Last NameFirst Name
Nick Name (athlete)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Current Age (athlete)*
Birthdate*

MonthDayYear
Date
School*
Grade *
Gender*
Phone Number
Please enter a valid phone number.
PARENTS INFORMATION
*Parent / Guardian (1)*
First and Last Name (Guardian 1)*

First NameLast Name
Email (Guardian 1)*
example@example.com
Phone Number (Guardian 1)*
Please enter a valid phone number.
*Parent / Guardian (2)*
First and Last Name (Guardian 2)

First NameLast Name
Email (Guardian 2)
example@example.com
Phone Number (Guardian 2)
Please enter a valid phone number.
*Emergency Contact*
Emergency Name*

First NameLast Name
Email (emergency)
example@example.com
Phone Number (emergency)*
Please enter a valid phone number.
HEALTH & MEDICAL INFORMATION
Do you have medical insurance?*
Insurance Company Name*
Policy/Member Number #*
Policy/Member Group Number #*
Policy Phone Number*
Please enter a valid phone number.
Physician's Name*

First NameLast Name
Physician's Number*
Please enter a valid phone number.
Does this athlete have any medical problems? (select all that apply)*

Allergies (food, insect, medicine, etc.)AsthmaMedical LimitationsMigrainesNosebleedsNoneOther
If yes, please explain.
Parental Authorization (Health/Medical)

I, ___________ assume all risks and hazards coincidental to running activities and hereby release, absolve, and hold harmless, Clarke County Board of Education, Clarke County Commissioners, Clarke County Employees, Athens Youth Academy Inc Track Club (AYATC), AYATC Board of Directors, organizers, supervisors, coaches, volunteers, participants, and parents supervising or transporting participants to or from such activities, from any claim for loss, damage, or injury that may occur as a result of my child's participation in Athens Youth Academy Inc Track Club. I hereby give the permission for any and all medical attention to be administered to my child in the event of accident, injury, sickness, etc., under the direction of Athens Youth Academy Inc Track Club, coach, assistant coach, or administrator, until such time as I may be contacted. I also assume full responsibility for the payment of any expenses associated with such treatment. The release is effective for a period of twelve (12) months from the date given below.
I have read and agree to the above conditions.*

YesNo
Signature*
Signature

Clear
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
RUNNING SEASON
Select All That Apply*

Cross-CountrySpring Track & FieldSummer Track& Field
EVENTS

Please select all events that you think your child would be interested in. Some event ages depends on the season.
Type a question*

50 Meters (5U -10U)100 Meters200 Meters400 Meters800 Meters1500/1600 Meters3000/3200 Meters80 Hurdles100/110 Hurdles200/300/400 HurdlesRelaysDiscusShot PutJavelinSoftball ThrowHigh JumpLong JumpTriple JumpStanding Jump
UNIFORM SIZES
SIZE CATEGORY*
Singlet*
Shorts*
T-Shirt*
Warm-Up Pants*
Warm-Up Jacket*
The Following Information Must Be Provided In Order For Athlete to Participate

Must Bring a copy of each
Copy of Birth Certificate*

YesNo
A Copy of Current "Physical" Form*

YesNo
A Copy of Medical Insurance Card*

YesNo
Parental Release for Interviews, Photography, Video-Recording
Parental Authorization

On occasion the Athens Youth Academy, Inc Track Club (AYATC) may be photographed, interviewed and/or videotaped. Doing so may be for purposes including but not limited to: promotional material, advertisements, presentations, programs, and internet sites. Your athlete’s name may also be used in conjunction with or by any media – including print, electronic, radio, and/or television. I, ______ , authorize the organization and professional staff to use the pictures taken in future track related activities, literature, and presentations. By signing this Release, I grant permission to AYATC, or anyone properly authorized by the organization to interview, photograph, audio-record, and/or videotape my athlete during track activities.
I have read and agree to the above conditions.*

YesNo
Signature*
Signature*

Clear
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
VOLUNTEERS

*Personal Info*
Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
*During Practice* - *Meet Days*
Select All That Apply

MondayTuesdayWednesdaySaturday (Meet Days)
More

Assistant Coach - DistanceCoach a Specific Field EventOther
Select All That Apply

Team Mom/DadPublicity Person - Emails, Photography, Website, etc.Organize End-of-Season BanquetAny other ideas or help you may have to offer (describe below)Other
Should be Empty:

AYA Trojans Track Club - Registration Form

ATHLETE INFORMATION

PARENTS INFORMATION

*Emergency Contact*

HEALTH & MEDICAL INFORMATION

RUNNING SEASON

EVENTS

UNIFORM SIZES

The Following Information Must Be Provided In Order For Athlete to Participate

Parental Release for Interviews, Photography, Video-Recording

VOLUNTEERS

*During Practice* - *Meet Days*

Emergency Contact

During Practice - Meet Days