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| ATHLETE REGISTRATION & PARENTAL CONSENT
FORM
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ATHLETE INFORMATION
Name:
Birthdate: _____/_____/_______ Age: Boy
[ ] Girl [ ]
School: Grade:
Address:
(STREET) CITY ZIP
Athlete’s Email: Home#:
T-Shirt Size: YS YM YL AS AM AL AXL AXXL
Uniform Size: YS YM YL AS AM AL AXL AXXL
PARENT INFORMATION
Parent/Guardian #1 Name: PHONE:
Email Address:
Parent/Guardian #2 Name: PHONE:
Email Address:
EMERGENCY INFORMATION
PERSON TO
NOTIFY IN CASE OF EMERGENCY OTHER THAN PARENT
NAME: PHONE:
RELATIONSHIP: WORK:
DO NOT FORGET A BIRTH CERTIFICATE, YOU CANNOT PARTICIPATE WITHOUT
ONE!!
EMERGENCY
MEDICAL AUTHORIZATION FORM
To Quicksilver Track Club Inc, it’s Head Coach, Executive
Director and staff members; I represent that I am the parent or legal guardian
of, ,
and that I have completed all the required registration forms. By my signature
below I hereby give my consent for the above named child to participate in
practices, track meets, travel and other activities sanctioned, sponsored,
and/or attended by Quicksilver Track Club of Atlanta Inc. (QTC). I authorize QTC
to sign the standard athlete's release form when entering my child in any
sanctioned event. Should I decide to withdraw my child from participation in
the club and its activities, I agree to notify the Head Coach in writing that I
am withdrawing my child.
Further, in consideration of my child being accepted in QTC,
I hereby indemnify and hold harmless Quicksilver Track Club Inc, and/or any
volunteer assistant coach or other club personnel against any and all rights
and claims which I have or which may arise in conjunction with my child's
participation or travel to and from practices, track meets, or other activities
attended by QTC. In the event the need
for emergency medical treatment arises and reasonable attempts to contact me at
the above numbers have been unsuccessful, by my signature below I hereby give
my consent for the administration of any emergency medical treatment deemed
necessary by Dr. ,
my preferred physician, whose phone number is ; or in the event the
preferred practitioner is not available I give my consent for the
administration of emergency medical treatment by an emergency medical team,
licensed physician or hospital chosen by the Club.
Facts concerning the child's medical history including
allergies, medications, and any physical impairment to which a physician should
be alerted are listed below. I represent that the list below is current and
accurate and includes all allergies. The undersigned further represents that
the above named child is physically fit and physical impairments that will in
any way effect the child's participation have been brought to the attention of
the Executive Director of QTC in writing.
List allergies,
medications, and other pertinent health information:
ATHLETES RELEASE
HOLD HARMLESS STATEMENT In consideration for acceptance of
my entry into the USA Track & Field/Youth Athletics Program, AAU Junior
Olympics, and all the meets associated with these programs, I intend to be
legally bound, do hereby, for myself, my heirs, executors and administrators
waive, release and forever discharge all rights and claims for damage which may
hereafter accrue to me against USA Track & Field, owners and operators of
facilities used for Youth Athletic activities in which I participate,
organizations which sponsor and/or conduct these activities, their agents
representatives, successors, and/or assigns for any and all damages which may
be sustained or suffered by me in my traveling to, participating in, and
returning from Youth Athletics activities.
Print or Type Name:
Signature: Date:
PARTICIPATION AGREEMENT
This Agreement between Quicksilver
Track Club, Inc. (QUICKSILVER) and ,
parent(s) of ,
is entered into this day of ,
20 ; for the purpose of
providing a clear understanding of the duties and responsibilities of each
entity, in order to insure smooth, efficient management of the Club; a complete
and harmonious season for parents, coaches and competitors; and to provide
quality training and participation for the athletes of QUICKSILVER.
Whereas, The 2010 track season will begin on or around
October 2009 and end on or around August 2010 and;
Whereas, QUICKSILVER will be participating in various Track
& Field Meets throughout the season that will require the maximum
dedication and output from each of its athletes, and their parents, and;
Whereas, QUICKSILVER will travel to many cities in these
United States, (and possibly to cities in foreign countries), and;
Whereas, There are entry fees that need to be paid for these
various meets, travel expenses to attend the meets, and other expenses related
to competition ranging from uniforms to facilities, equipment to insurance,
and;
Whereas, I have received in writing a schedule of events,
practice schedules, and an approximate cost for the summer;
IN
RECOGNITION OF THE ABOVE, I (WE) HERE-BY AGREE:
1.
To pay the $235.00 registration fee to QUICKSILVER by May
21, 2010.
2.
To make sure that my child will be at every QUICKSILVER practice, scheduled or
called during the season at the specified times.
3.
To make certain that my child will participate in every event requested by the
coaching staff.
4.
To pay all expenses assessed my child associated with travel, either in legal
tender or by contributing equitable time to the QUICKSILVER Parent Booster
Club, or a combination of both of the above, by the required deadlines.
5.
To make certain that my child abide by all QUICKSILVER rules now or hereafter established.
6.
To provide in writing all schedule conflicts before the running season begins,
and if it becomes necessary for my child to miss a practice, notify the
coaching staff in writing, as early as possible, of the conflict.
7.
To abide by the spirit and the letter of this agreement, understanding that it
is drawn and executed for the welfare of the club and each young person
involved; and further, understanding that the failure of any one individual to
live up to this agreement can cause the failure of all to participate.
IN WITNESS WHEREOF I HAVE HERETO SET MY
HAND.
Signed: Date: