Premier Performance Athletics Registration Form 2020
Participant's First Name *
Your answer
Participant's Last Name *
Your answer
Address *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Race *
Gender *
Cell Phone for Text Notifications
Your answer
Email Address to Receive Track Information
Your answer
Parent's Information
Father's Name
Your answer
Father's Email address
Your answer
Father's Cell Phone
Your answer
Mother's Name
Your answer
Mother's Email Address
Your answer
Mother's Cell Phone
Your answer
Emergency Contact
Name, Relationship, Contact Number:
Your answer
School Information
School Name
Your answer
School District
Your answer
Participant's Grade
Your answer
2018 Medical Release
Medications and Fequency taken by the Participant
Your answer
Medications in Participant's Possession
Your answer
Medical History
List any pertinent medical history or chronic medical problems, such as a heart condition, asthma, seizures, or severe allergic reactions. Please inlcude any special precautions, injuries, etc that should be considered)
Your answer
Medical Insurance
Insurance Company, Name of Insured and Policy or Group Number
Your answer
Athlete's Size Information
T-Shirt Size
Your answer
Uniform Top Size
Your answer
Uniform Bottom Size
Your answer
Shoe Size
Your answer
Authorization and Release
Medical Authorization *
I release the coaching staff and Premier Performance Athletics from any responsibility for bodily injury my child may receive while participating in the program. I understand that I am responsible for any medical fees accrued by my child as a result of medical attention. In the case an emergency and a parent cannot be reached by phone, I authorize an officer or member of Premier Performance Athletics staff to obtain medical treatment for my child and any hospital medical staff requested by a physician to make such examinations and render such medical treatment which in his/her judgment may be deemed necessary for my child’s health and welfare.
Internet Authorization *
I agree to my child's image, participating event or first name only appearing on the Premier Performance Athletic's website
Partipation Release *
I represent that I am the parent or legal guardian of the above named minor child, and that I have completed all of the required registration forms. By my signature below, I hereby give my consent for the above named child to participate in practices, track meets, road races, travel and other activities sanctioned, sponsored, and/or attended by Premier Performance Athletics (PPA). I authorize the Coaches, Board of Directors, and/or other staff members to sign the standard athlete's release form when entering my child in the USA Track & Field, AAU or TAFT sanctioned events.
How did you hear about us? Referred by? *
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Electronic Signature *
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