Goulds Panthers Track Club

Athlete Information

Athlete's Name

First Name Last Name

Birth Date

Month Day Year

Age

Grade:______

Gender

Male Female

T Shirt Size

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information

Name

First Name Last Name

Home Number

Area Code Phone Number

Cell Number

Area Code Phone Number

E-mail

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Waiver of Liability, Release Assumption of Risk & Indemnity

I hereby give my approval for my child’s participation in any and all activities prepared by Goulds Panthers Track Club. In exchange for the acceptance of said child’s candidacy by Goulds Panthers Track Club, the applicant and/or participant releases and forever discharges, and covenants not to sue the Goulds Panthers Track Club, from all liabilities, claims, demands, losses, or damages of the Participant caused or alleged to be caused in whole or in part by the action, inaction or negligence of Goulds Panthers Track Club, including but not limited to negligent rescue operations, negligent security, travel and recreation operations and activities, and further agree that if despite this release and waiver of liabilities, assumption of risk, and indemnity, the Participant or anyone on behalf of the Participant makes a claim against Goulds Panthers Track Club, the Participant and/or his/her parent or guardian will indemnify, save and hold harmless Goulds Panthers Track Club from any litigation expenses, attorney’s fees, loss, liability, damage, or cost which may be incurred as the result of such a claim. The Participant understand that:

(a) athletic activities involve risks and dangers of serious bodily injury, including permanent disability, paralysis, and death,

(b) these risk and dangers may be caused by the Participant’s own actions or inactions, the actions or inactions of others participating in the activity, the condition in which the activity takes place or the negligence of others,

(c) there may be other risks and social and economic losses either not known to the Participant or not readily foreseeable at this time, and the Participant accepts and assumes all risks and all responsibility for losses, costs, and damages the Participant incurs as a result of participation in the activity.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Goulds Panthers Track Club, and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized for the duration of the camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

REGISTRATION FEE IS NOT REFUNDABLE.

My Products

Registration $ 250.00

Goulds Panthers T Shirts $ 15.00

T-Shirt

Total $ 0.00

GPTC Registration Form