This must be completed- legibly- and signed in all areas by both the athlete and his/her parent or guardian.  By signing this form the participant affirms having read it.

 

Name ___________________________________________________________________________________________

              Last                                                First                                         Birth Date             Age                 Gender                 

Primary Contact:  Parent or Guardian

Name ________________________________________  Address _________________________________________Zip__________

Phone _____________________________________________ Alternate Phone ___________________________________________

 

Secondary Contact:  ____Parent/Guardian    ____Other

Name ________________________________________  Address _________________________________________Zip__________

Phone ___________________________________ Alternate Phone ____________________________________________________

 

Primary Insurance Co. ___________________________ Primary Group/Policy # __________________________________________

 

Family Physician Name __________________________ Physician Phone ________________________________________________

Please elaborate on any medical conditions of which we should be aware:

 

Any medications currently being taken:

 

Any allergies:

 

If none, please write None.

 

 

Signed ________________________________________  Date: _________________________

              Participant

 

Participant, ____________________________ has my permission to participate in training, competition, events, activities and travel sponsored by the Jefferson County Jets Track Club or any AAU/USATF meet.  I approve of the leaders who will be in charge of this program.  I recognize that the leaders are serving to the best of their ability.  I certify that the participant has full medical insurance with the company listed above.  I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities described above. 

Signed ___________________________ Relationship: _____________________  Date: ________________

If, during the course of my daughter’s/son’s activities in track, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical/dental care.  I will assume financial responsibility for bills incurred through my insurance company. 

Signed ____________________________  Date: __________________________________________________

             Parent or Guardian

 

Or

I do not authorize emergency medical/dental care for my daughter/son.

Signed: __________________________________________________  Date: _____________________________________________

              Parent or Guardian

 

STATE OF ___________________________________  COUNTY OF __________________________________________________

SWORN TO BEFORE ME,  a Notary Public, by said ____________________________________ personally know to me this __________________ day of ______________________, ,20 ______.

____________________________________________  My Commission Expires _______________________________

Notary Public

 
 
 
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