CHARLOTTE PANTHERS TRACK & FIELD CLUB REGISTRATION APPLICATION

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 _______________