WALTHAM TRACK CLUB

88 Russell Street

Waltham , MA 02453

781-893-3828

(walthamtrackclub.com)

CROSS COUNTRY REGISTRATION FORM

Child's Name_________________________________________________________________________________  

Age_______   Date of Birth_________________  Sex :     M     F       Grade______ School_____________________

Address_________________________________________________ZipCode_____________Phone______________

T-shirt Size:  YS   YM   YL   AS   AM   AL   AXL

Preferred Practice Days  (number top 3 choices)  Sun____  Mon____  Tues____  Wed____  Thurs____

Parent's Email (PLEASE PRINT NEATLY)__________________________________________________________

(Team Updates Will BeSent Via Email)

2010 USATF Membership # _____________________________________________

If an interested cross country member does not have a 2010 USATF membership, one may be obtain online at

www.usatfne.org , click on membership and fill in required info. A number will be assigned immediately online.

(Membership dues are $20.00 – they only take VISA)

PLEASE RETURN THIS COMPLETED FORM, ALONG WITH DUES ($85.00(Waltham Residents) $95 (non Residents) - $100 AFTER AUGUST 31) payable to Waltham Track Club), to Waltham Track Club, c/o Joe Tranchita , 88 Russell Street , Waltham , MA 02453 . Cross country registrations must be received by September 13, 2010.

PLEASE SPREAD THE WORD AND HELP US GET AS MANY KIDS INVOLVED AS WE CAN! THANKS!!!

As the parent or legal guardian of the above applicant, I fully understand that participation in athletics, in this case cross country, could result in both minor and serious injury and even death. I further understand that to minimize the risk of injury or harm, the applicant should have had a physical within the past year, clearing applicant for sport activities. I assume any and all risks associated with the above applicant's participation as a member of the Waltham Track Club and I hereby waive and release the Waltham Track Club, its coaches and representatives, of any and all rights for damages or injuries suffered while participating with the Waltham Track Club during a scheduled practice, conditioning session or competition; while traveling to or from a scheduled practice, conditioning session or competition; or during any other Club related activity.

I give the Waltham Track Club permission to use any picture or photo likeness of me in newspaper releases and related sport articles or on the Club's Web Site and to distribute, broadcast and exhibit these without charge, restriction or liability, but only for the purpose of advertising or promoting the programs of the Waltham Track Club and the sport of track and field. In no event, however, will such usage constitute an endorsement of any product or service, without my specific written permission.

(Please Circle) Yes No

Signature of parent or guardian of above applicant___________________________________Date_________________

Relation to applicant (mother, father, sister, etc.)__________________________________________________________

DUES - $85.00(Waltham Residents)

              $95 (non Residents)

              $100 (AFTER AUGUST 31)