Membership Application

Applicant Information

Name:

Date of birth:

Email:

Phone:

Current address:

City:

State:

ZIP Code:

Qualifying Race INFORMATION*

Name of Race:

Distance:

Overall Time:

Miles Per Minute:

City:

State:

Date of Race:

Overall Place:

Age Group:        

Age Group Place:

Emergency Contact

Name of a relative:

Address:

Phone:

City:

State:

ZIP Code:

Relationship:

Fleet Feet Sports Training Program-Completed**

Fleet Feet Sports Training Program

Date of Training Program

Fleet Feet Sports Coach

Other Races (2016)

Race Name / Location  / Date

Race Distance  / Time

Signatures

I have read and understand the Fleet Feet Sports Racing Club Member Good Sportsmanship Code AND Fee Reimbursement policy, both of which, I agree to abide by. I authorize the verification of the information provided on this form.

Signature:

Date:


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