Name Gender BirthDate Address
City Zip Home Phone#
Cell# US Citizen (for USATF purposes) Yes No
Parent/Guardian Cell# Parent/Guardian Cell# (Parent)Email
USATF#(Required) Physician Phone Address
Hospital of Choice Medical Conditions (e.g. asthma,allergies)
Emergency Contact (Other than parent)
Name Phone Relationship
I/We, the undersigned, assume all risks and hazards incidental to participating with the Club Northwest, including transportation to and from club activities. I/We also hereby authorize the Coach and/or Administrator of the team to represent me while entering the athlete into competitions via online entry, faxed entry, or emailed entry; or registering for USA Track and Field (USATF) or Club Northwest (CNW) memberships. I/We hereby agree to hold harmless the Club Northwest Officers, Coaches and Assistants from any claim arising out of an injury to myself and/or my/ourchild.
I, the undersigned athlete, understand that I am committing to Club Northwest, which is a registered competitive athletics club with USATF. I understand that I may not compete for another club for a period of one hundred (100) days following the last competition as a member of Club Northwest without the permission of the coach, club president, my parents, and Pacific Northwest Track & Field (PNTF). I agree to follow all clubrules.
Athlete Signature Date
Parent/Guardian Signature Date