WALTHAM TRACK CLUB

88 Russell Street

Waltham, MA 02453

781-893-3828

(walthamtrackclub.com)

OPEN TEAM REGISTRATION APPLICATION

_____New Member   _____Renewal

Name _______________________________________________                      Sex:    M      F            Date __________________

                 (last)                                                       (first)

Address __________________________________________ City ____________________ State____ Zip Code_________

Home Phone ________________________ Cell Phone _________________ Email _______________________

Age ________ Date of Birth ____________________ Height ________ Weight _________

Do you have any physical handicaps: (injuries, allergies, etc.) Be specific ______________________________________

________________________________________________________________________________________________

Have you had a recent physical? Yes No How long ago? ____________________

If a student, please give grade and school attending: ______________________________________________________

If you work, give type and place of occupation ____________________________________________________________

Are you registered with USATF-NE? Yes No If yes, give number ___________________________________

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Please fill in the following information for the WTC coaching staff

Which program are you registering for?

_______ Track & Field _______ Road Racing _______ Mommy Track ______ Injury Prevention & Conditioning

Please list specific events or sports that interest you: _______________________________________________________

Please list any awards, honors and personal bests for track and field events or for any other sport that you have participated in:

_________________________________________________________________________________________

Short term objectives/goals: _____________________________________________________________________________

__________________________________________________________________________________________________

Long term objectives/goals : _____________________________________________________________________________

___________________________________________________________________________________________________

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 clearly understand that with any sport activity, both minor and serious injuries and accidents may occur and I accept the risks that go along with my participation.

Signature of applicant (or parent or guardian if under 18) ______________________________________ Date __________

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

Applicant = s Signature (or parent = s if under 18) _________________________________________ Date ________________

Open Team Dues: $200.00