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Name (Last) __________________________________ (First) _____________________________________

Medical Information/Waiver:

To whom it may concern: I, the parent/guardian
Of ______________________________________ Hereby authorize a club representative of Charlotte Panthers Track & Field 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 nonemergency 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 waiver and release all claims for damages I may now hereafter have arising out of the above named person’s participation in any activities of Charlotte Panthers Track & Field Club. I further state that to my knowledge, applicant has no health problems or preexisting conditions, not previously mentioned that limit his/her training or activity level.

Insurance & Policy #: __________________________________________________________________ List any allergies (medication, food, etc.)___________________________________________________ Athlete Photographs/Images: By signing below I understand and agree that Charlotte Panthers Track & Field Club has my permission to take and use my child’s photographs or digital images for official Club purposes.

Parent/Guardian Signature________________________________________________ Date ___/___/___

REGISTRATION FEES: (THIS FEE IS NON-REFUNDABLE) $135.00 (uniform included) 6-Under $110.00
(uniform included) (Siblings – 15% Discount Multiple Athletes)
Fee Includes: (Club Membership, Team Uniform, Team T-Shirt, (AAU) Membership-Insurance, Banquet Fee & More)

(For Office Use, Do Not Write Below This Section )

Registration Fee $___________ Physical Form___________ Release of Liability Agreement___________ Copy of Birth Certificate_________ Uniform Sizes Top _________ Bottom ____________ T-Shirt Size _______________



Release of Liability Agreement

I/ we agree to indemnify, save and hold the CHARLOTTE PANTHERS TRACK&FIELD CLUB, LLC It’s officers, agents,representatives, coaches and employees from and against all rights, actions ,causes, claims of liabilities, costs of expenses of any kind as well as attorney’s fees on appeal, of whatsoever kind or nature to which the organization may be subjected as a result of my participation in the activity for which I am registering. I further agree that this release shall apply in the event that (I/ my child) is disabled, injured, or incur disease of a temporary or permanent nature while participating in this activity. I/ we further agree to return any and all property issued to me upon (request), expiration of this activity or whenever I have ceased to be a member of said activity, or in the event the equipment is lost, stolen or damaged to reimburse the CHARLOTTE PANTHERS TRACK & FIELD CLUB, LLC for said property. I/ we certify that I have fully read and understand the contents of this form and that I fully agree to all terms and conditions. This contract shall not become effective until signed by the participant, parent (in case of minor) and agent of the organization and accepted by the Charlotte LLC.

ATHLETES SIGNATURE: ________________________________________________Date: ___/___/_____

ATHLETES SIGNATURE: ________________________________________________Date: ___/___/_____

ATHLETES SIGNATURE: ________________________________________________Date: ___/___/_____

PHONE NUMBER: ___________________________________
Name of Insurance Company and Policy Number, in case of medical emergency or injury.

_____________________________________ _____________________________________

E-Mail: charlottepantherstc@yahoo.com Website: http://www.charlottepantherstrackclub.com Contact: Coach AJ (336) 451-0370 or Coach Reggie (704) 900-4372