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                                                                        

Participation Contract:Parent/Athlete

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