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) ___________________________________

 

 What are your areas of interest? Please check all that apply:

 

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: $180.00 for (May-Aug2010)

 

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.

 



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 _______/______/_______



You can either pay online (click on button below)  OR  Mail in payment to 9433 S. Forest Ave. Chicago, IL 60619  OR  Bring payment to track during scheduled times

Click below to pay online for One athlete ($180.00) (see sibling online payment options below)


Click below to pay online for Two Siblings (with $20 discount)=$340.00


Click below to pay online for Three Siblings or more =$450.00



Click below to pay online for 10 two hour one-on-one training sessions(weekly schedule set by client & coach)=$650.00



If you have any questions or concerns please call Coach Collins directly at 773.480.0106

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