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San Antonio Track Club

Personal Information Form

Participant’s

Name:____________________________________________________________________

Mailing

Address:_________________________________________________________________

City: ______________________________ Zip: ___________ Phone: ____________

Birth Date: _______/______/_______ Grade: _______ School: _______________

Parent’s or Guardian’s Name: ____________________________________________

Email: __________________________________________________________________

Address (if different):__________________________________________________

Home Phone (if different): ______________________________________________

Work Phone: _____________________________________________________________

Cell Phone: _____________________________________________________________

Emergency Contact Information (if both parents unavailable)

Contact : _______________________________________________________________

Relationship to Child: __________________________________________________

Phone:___________________________________________________________________

Health History & Emergency Medical Information

In an emergency, the San Antonio Track Club has my permission to obtain

medical treatment for my child, call an ambulance, or transport my child

to any available physician or hospital at my expense, with the following

restrictions (if applicable):

Date of Last Tetanus: ___________________________________________________

Child’s Physician: ______________________________________________________

Phone: __________________________________________________________________

Are there any allergies, special medical conditions, special needs, or

restrictions to be aware of? Yes No

Please List: ____________________________________________________________

Preferred Hospital: _____________________________________________________

Address: ________________________________________________________________

Phone:___________________________________________________________________

Liability Wavier and Conditions of Membership

By my signature on this application I give permission for my child to participate in the club

and its events and hereby affirm that my child is in proper physical condition in order to

participate in all San Antonio Track Club training and events.

In consideration of the acceptance of this entry, I agree to assume all risk of injury or

fatality to my child (including all medical expenses), and all risk or damage or loss of property

arising out of his/her participation in this organization and its activities. I, for

myself, my heirs, executors, administers and assigns do indemnify & hold harmless the sponsors,

volunteers, parents, coaches and representatives of the San Antonio Track Club from any and all

liability, claims, demands, actions, loss and/or damage arising out of my child’s participation

in the San Antonio Track Club and it’s activities.

I understand that travel, and entry fees, are the financial responsibility of the parents.

Parent’s Name(print)____________________________________________________________________________

Parent’s Signature/Date_________________________________________________________________________