Tru Speed Track Club of Mesquite

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Runner Registration Form

RUNNER 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 Runner:

* Insurance Carrier:

* Policy #:

* Medical Problems:

* Medications:

WAIVER INFORMATION

I CERTIFY: I am the Parent or Guardian of the above named applicant and the information is true to the best of my knowledge. I also acknowledge the reserved rights of the Tru Speed Track Club and understand that the Tru Speed Track Club does not provide Medical Coverage.

Parents Signature: _______________________________________

Date ______________________

I/we agree with the above *

* indicates required fields

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Runner Registration Form