WALTHAM TRACK CLUB

88 Russell Street

Waltham, MA 02453

781-893-3828

(walthamtrackclub.com)

_____Winter Track  _____ Spring/Summer Track   ____High School Membership   ____Travel Team

______New Member ______Renewal

Name__________________________________________ Sex:    M   F      Date__________________

            (last)                                   (first)

Address____________________________City_____________________State_____Zip Code________

Home Phone___________________________Cell Phone________________________

Parent Email(print neatly)________________________________Child's Email____________________

Age________ Date of Birth____________________ Height________ Weight_________

Does applicant have any physical handicaps: (injuries, allergies, etc.) Be specific _____________________________________________________________________________________________________________________________________________

Has applicant had a recent physical?    Yes   No

When was applicant's last physical?_________________________________

If a student, please give grade and school attending _______________________________________________________

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

============================================================================================   

Name of Parent or Guardian of Applicant___________________________________________________________________

Address___________________________City___________________State__________Zip_____________

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

As the parent or legal guardian of the above applicant __________________________________, I fully understand that participation in athletics, in this case track and field, 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. 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.

.   

Signature of parent or guardian of above applicant_______________________________________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

Signature of parent or guardian of above applicant__________________________________________Date________________

CLUB DUES

WINTER TRACK -

Waltham Residents: $65 for 1 child,  $80 for 2 children, $95 for 3+ children  

 Non Residents:  $75 for 1, 100 for 2, $125 for 3+ children   

PLEASE NUMBER PREFERRED PRACTICE NIGHTS (1ST, 2ND CHOICE)

____Sun   ____Mon  ____Tues  ____Wed

SPRING/SUMMER TRACK

Waltham Residents: $95 for 1 child,  $115 for 2 children, $125 for 3+ children  

           Non Residents:  $105 for 1, 125 for 2, $135 for 3+ children

SUMMER TRACK TRAVEL TEAM

Current Spring Track Members - $30.00

Non Members - $75.00

Annual High School Membership - $200.00

 

T-SHIRT SIZE - CIRCLE ONE

YOUTH: S   M L   ADULT: S M L XL