VENTURA COUNTY YOUTH TRACK CONFERENCE
CLUB MEMBERSHIP APPLICATION
[     ]  [     ]
Age Group

PLEASE PRINT                                                                                   CLUB __________________

ATHLETE  INFORMATION

LAST NAME

FIRST NAME

M.

M/F

BIRTH DATE

/    /

SCHOOL

GRADE

ADDRESS

PHONE

YRS EXPERIENCE

YEARS WITH USATF
 

USATF # FOR CUR YR

PARENT/GUARDIAN  INFORMATION

LAST NAME

FIRST NAME

HOME PHONE

WORK PHONE

PAGER/ FAX/OTHER PHONE
 

HOME ADDRESS

 

CITY

ZIP CODE

E-MAIL ADDRESS

 

PARENT VOLUNTEER JOB PREFERENCES--COACH, TIMER, RIBBON TABLE, ZONE JUDGE, STAGER, STARTER, ANNOUNCER

(OPTIONAL) PARENT NOT IN THE HOME IF APPLICABLE

LAST NAME

FIRST NAME

HOME PHONE

WORK PHONE

ADDRESS

EMERGENCY CONTACT (If parent or guardian is unavailable)

LAST NAME

FIRST NAME

EMERGENCY PHONE

RELATIONSHIP (Friend - Relative)

MEDICAL INFORMATION

DR. NAME

DR. PHONE

PHYSICIAN ADDRESS/LOCATION

 

INSURANCE COMPANY

 

INSURANCE CO. PHONE NUMBER

POLICY NUMBER

GROUP ID

LIST ANY/ALL CONDITIONS OR LIMITATIONS WHICH MAY AFFECT THE APPLICANT’S ABILITY TO PARTICIPATE IN THIS SPORT:

DATE OF OCCURRENCE OR ONSET

LIST ANY ALLERGIES TO MEDICATIONS:

DATE OF LAST TETANUS SHOT

 

IF YOUR CHILD MUST BE TAKEN TO A MEDICAL FACILITY, PLEASE CIRCLE ONE:

NEAREST EMERGENCY FACILITY-OR-ONLY TO: ___________________  _________________
                                                                                        (FACILITY)                                 (LOCATION)

DO YOU HAVE ANY SPECIFIC INSTRUCTIONS OR REQUESTS FOR THE HANDLING OF YOUR CHILD’S MEDICAL NEEDS?

 

UNIFORM SIZES

PROOF OF AGE

FEES PAID

TOP

SHORTS

BIRTH CERT.

OTHER

CHECK #

 

CASH

 

OTHER

 

EMERGENCY TREATMENT RELEASE

It is understood by the undersigned Parent(s)/Guardian(s) of __________________ that in case of serious illness or accident, a reasonable
                                                                             (CHILD’S NAME)
effort will be made to contact me, my spouse, or the emergency contact listed on this application form, before any medical or dental care is commenced, providing time and conditions permit. If, however, I or my spouse cannot be reached with reasonable diligence, or in the case of an immediate emergency, I hereby authorize the representatives of the Club to arrange for and to consent to such medical or dental care as may be recommended by a licensed physician or dentist. Such medical and/or dental care shall include, but is not limited to, routine diagnostic tests or examinations, including blood tests, radiographic or laboratory examinations, anesthesia, or any other treatment or care to be rendered under the general or specific supervision and upon the advice of a physician or surgeon licensed under the provisions of the Medical Practice Act or a dentist licensed under the Dental Practice Act.  I further understand that this authorization is given in advance of any specific diagnosis, treatment, or care. I agree to hold harmless the Club, it’s representatives, or any adult acting as an agent for the Club, from any liability arising out of the use of, or reliance on, this document. This authorization is given pursuant to the provisions of Section 25 of the Civil Code of the State of California. This authorization shall remain in effect until December 31, 20_____, or no longer than one (1) year from the date of signing.

______________________________ ___________ _______________________________ ____________
Parent/Guardian                                     Date               Witness                                                  Date

CONDITIONS OF PARTICIPATION

As a condition of acceptance as a member of this organization, the Applicant and his/her parent/Guardian agree to the following conditions:
THE APPLICANT AGREES TO:
1. Conduct myself in a thoughtful, respectable manner at all times and to refrain from all offensive language.
2. To treat all club and school property with care and respect.
3. To return any equipment or property which is not mine to the club within one week of the last meet. This includes my uniform if the club requires its return.
4. To abide by all of the rules, directions, and decisions of coaches and officials.
5. To participate fully and support all team activities to the best of my ability in all practices and meets.
6. To maintain a "C" grade average or better in school with no "F" grades.

 ____________________________________ __________________
APPLICANT SIGNATURE                                                        DATE

THE PARENT/GUARDIAN AGREES TO:
1. Provide timely transportation for my child to and from all practices and meets without fail.
2. Support the team and my child’s efforts by working at all Home meets, as a coach, or as a Board member.
3. Set an example of sportsmanship and fair play at all times.
4. Conduct myself in a thoughtful, respectable manner at all times and to refrain from all offensive language.

____________________________________ __________________
PARENT/GUARDIAN SIGNATURE                                          DATE