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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:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
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1999
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2015
2016
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2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
*
Email:
*
Gender:
M
F
*
Grade:
K
1
2
3
4
5
6
7
8
9
10
11
12
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