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CHICAGO STRIDERS TRACK CLUB REGISTRATION & MEDICAL RELEASE FORM
CLICK here to Print this Page for Registration. FULL payment MUST be submitted with forms. If you choose to pay online (see below) please bring this registration form to the next practice. Thank you! We are looking forward to an enjoyable track season! Athletes Name (last) ____________________ (first) _________________________ (mi) _____ (nickname)_________ Date of Birth _____/______/______ Male ______ Female ______ Current Age ______ School ________________________ Street Address ______________________________________________________________________________________ City __________________________ State ________________ Zip ______________ Home Phone (______)_______________________________ Family E-Mail Address _______________________________________ Parent/Guardian ___________________________________________ Relationship ________________________________ Address __________________________________________________ Phone Number (______)_______________________ Phone/Work (______)_____________________ E-mail address (if different from above) ___________________________________ Long distance ___ Middle distance ___ Sprints ___ Hurdles ___ Relays___ Javelin ___ Shot put ___Discus ___ High jump ___ Long jump ___ Pole vault ___ Don't know yet____ Fee for One Athlete: $185.00 for (June-Aug2008)
Fee includes one year Chicago Strider Track Club membership, United States Association of Track & Field membership, entry fees for USATF Jr. Olympic State Meet and club T-shirt. All fees are due no later than June 14, 2008
A copy of your athletes birth certificate must accompany this application Medical Information/Waiver: To whom it may concern: I, the parent/guardian of ________________________________ hereby authorize a club representative of Chicago Striders Track Club to seek and sign for medical treatment for my child, a member of said club, in an emergency situation. I also authorize that the same representative 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 wavier and release all claims for damages I may now or hereafter have arising out of the above named person’s participation in any activities of Chicago Striders Track Club. I further state to my knowledge, applicant has no health problems or preexisting conditions, not previously mentioned that limit his/her training or activity level. Parent/Guardian Signature ____________________________________________________________ Date _______/______/_______
Click below to pay online for One athlete ($185.00) (see sibling online payment options below) Click below to pay online for Two Siblings (with 10% discount)=$333.00 Click below to pay online for Three Siblings(with 10% discount)=$499.50 Click below to pay online for 6 months one-on-one(weekly schedule set by client & coach)=$800.00 |
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