Eastside Track Club

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PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

INFORMED CONSENT/ASSUMPTION OF RISK

I agree to participate in the track and field training activities and programs of Eastside Track Club and to the use of it’s facilities, equipment, and services. I recognize and understand that the program is not without varying degrees of risk, which may include, but are not limited to the following: Injury to the musculoskeletal and/or cardio respiratory systems which can result in serious injury or death due to improper use or failure of equipment, or injury or death due to a medical condition, whether known or unknown by me. I am aware that any of these above mentioned risks may result in serious injury or death.

I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in Eastside Track Club and accept full responsibility for any injury that may result from participation in any activity, class or physical fitness program. I herby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a fitness program designed by Eastside Track Club. Eastside Track Club informed me that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in Eastside Track Club.

In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily participating in the activities made available by Eastside Track Club, and with my full understanding of all of the above, I hereby waive, release, remise and discharge Eastside Track Club and its agents, employees and volunteers, of any and all liability, claims, demands, actions or rights of action, or damages of any kind related to, arising from, or in any way connected with, my participation in Eastside Track Club programs.

If I am signing on behalf of a minor child, I also give full permission for any person connected with Eastside Track Club to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.

Eastside Track Club Waiver Release

I have fully read and fully understand the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property.

I/we agree with the above *

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