Track Registration Form

Capital Area Track Club II Registration Form

Athlete Information

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Grade

School

Gender

M/F

Guardian / Mother Name*

First NameLast Name

Guardian / Mother Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

Guardian / Father Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

example@example.com

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Insurance Carrier

Name of Policy Holder

Subscriber ID/Group Number

Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?*

YesNo

Please describe*

Name of Physician*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Release of Liability

I, the parent/legal guardian, hereby authorize the coaches, assistants, assigned chaperones and/or representatives of the Capital Area Track Club II to seek medical treatment, for my child, a member of said club, in an emergency situation. I also authorize that the same representatives of the Capital Area Track Club II be allowed to sign for medical treatment in non-emergency situations when my child is traveling with the club or when I am unable to be reached by phone. I also agree for myself, my heirs and personal representatives to waive and release all claims for damages I may now hereafter have arising out of the above named person’s participation in any activities of the Capital Area Track Club II. I further state that to my knowledge, the above named athlete has no health problems or preexisting conditions, not previously mentioned that limit his/her training or activity level. At any time a previously unknown condition becomes evident, I agree to immediately inform the head coach of the Capital Area Track Club II and obtain medical clearance if requested for continued participation.

I acknowledge that the Capital Area Track Club II does not provide individual insurance coverage for club members and agree to provide a current copy of the above named athlete’s medical insurance coverage. I further agree to be solely responsible for any expenses incurred as a result of an injury sustained while participating in a club attended event.

I have read and agree to the above conditions*

YesNo

Photo Waiver

ACKNOWLEDGE AND CONSENT: For both internal and external use, I acknowledge that the Capital Area Track Club II may compile and use photographs and video images of the above name individual, a minor, for use in all club related publications to include but not limited to videos, website, and written materials such as sponsorship packets or club advertisements. I hereby waive all rights to monetary compensation resulting from the use of images of the above name athlete.

Confirmation E-mail*

Signature*

After completing this form, please click the Submit button below. You will receive a confirmation email. If you do not receive the email within five minutes, please check your spam; otherwise, please contact us at catc2@yahoo.com.