SUPERSONICS TRACK REGISTRATION
NAME _____________________________ AGE____ SEX____ DATE OF BIRTH________________
ADDRESS_________________________________________________________________________
( include street, city, and zip code)
SCHOOL____________________________ GRADE________ HT__________WEIGHT___________
PARENT/GUARDIAN_____________________________________EMAIL ______________________
HOME PHONE#__________________________WORK PHONE#_____________________________
EMERGENCY PHONE#________________________REGISTRATION FEE $50.00 (non-refundable)
STATEMENT OF PURPOSE
THE SUPERSONICS TRACK CLUB REPRESENTS THE EFFORTS OF CONCERNED PROFESSIONALS & NON-PROFESSIONALS WHO BELIEVE THAT INCORPORATING ATHLETIC ABILITY INTO FRIENDLEY ORGANIZED COMPETITION RESULTS IN THE EFFECTIVE DEVELOPMENT OF YOUTH IN ASSUMING PRODUCTIVE AND RESPONSIBLE ROLES WITHIN THEIR HOMES, SCHOOLS, AND COMMUNITIES.
AGREEMENT
UPON SIGNING THIS MEMBERSHIP APPLICATION YOU AS A PARENT OR GUARDIAN ARE 1) DEMONSTRATING SUPPORT FOR THE FOREMENTIONED STATEMENT OF PURPOSE: 2) AGREEING TO PROVIDE REINFORCEMENT AT HOME IN THE IMPORTANCE OF PROMPTNESS, HARD WORK, FAIR PLAY, AND TEAM WORK: 3) AGREEING TO WAIVE ALL CLAIMS AGAINST CLUB OFFICIALS, AND CLUB SUPPORT ORGANIZATIONS.
MEDICAL HISTORY
FAMILY DOCTOR__________________________________PHONE#______________________________
INSURANCE CO/HEALTH PLAN______________________________POLICY#_________________________
CHECK THE FOLLOWING. USE YES OR NO AS REQUIRED AND GIVE APPROPRIATE DATES.
EAR INFECTION__________ ALLERGIES________ DISEASES
RHEUMATIC FEVER_______ HAY FEVER______ CHICKEN POX________
CONVULTIONS____________ POISON IVY_______ MEASLES____________
DIABETES____________ INSECT STING_________ GERMAN MEASLES________
ABNORMAL BEHAVIOR____________ PENICILLIN__________ MUMPS___________
OTHER DRUGS___________ASTHMA____________________
CHRONIC RECURRING ILLNESS_____________________________________DATE OF MAJOR OPERATIONS___________________________
ANY OTHER DISEASE OR EXPLANATION OF ABOVE ITEMS: ____________________________________________________
DATE OF LAST PHYSICAL________________________________
PARENT/GUARDIAN AUTHORIZATION
THE MEDICAL HISTORY IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THE APPLICANT HAS MY PERMISSION TO PARTICIPATE IN ALL RUNNING EVENTS OF THE TRACK CLUB, EXCEPT THOSE CHOSEN BY ME OR A PHYSICIAN. IN CASE OF AND EMERGENCY, I HEREBY AUTHORIZE THE OR AN AUTHORIZED ADULT OFFICER TO HOSPITALIZE, SECURE PROPER MEDICAL TREATMENT FOR, AND TO AUTHORIZE INJECTIONS, ANESTHSIA, OR SURGERY FOR MY CHILD, WHOSE NAME APPEARS ABOVE.
SIGNATURE OF PARENT/GUARDIAN DATE PRINT NAME HERE