Largo Elite Track Club Registration Form

Athlete Information *

First

Last

DOB *

Age *

Gender *

Male
Female

Athlete's Address *

Address Line 1

City

State

Zip Code

Guardian Information

Mother/Guardian Name

First

Last

Address Same as Athlete?

Yes
No

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mobile

Email

Confirm Email

Father/Guardian Name

First

Last

Address Same as Athlete?

Yes
No

Address

Address Line 1

City

State

Zip Code

Mobile

Email

Confirm Email

Health Information

Insurance Carrier *

Insurance ID *

Emergency Contact Information

Name *

First

Last

Relationship to Child *

Phone *

Name *

First

Last

Relationship to child *

Phone *

Upon submitting this form, I hereby assume all of the risks of my or my child participating in any/all activities associated with Largo Elite Track Club, Inc., including by way of example and not limitation, any risks that may arise from negligence or carelessness carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault, or actions of any kind which may hereafter occur to me including my traveling to and from this activity. Further, this shall authorize any doctor to commence immediate treatment in the event of any accident, illness, or injury to the athlete, and the undersigned shall be liable for payment thereof, without necessity of further release or authorization whatsoever. The undersigned also acknowledges and agrees that pictures and/or videos may be taken of the named athlete and used to promote the track club in current year and future. I further agree that I will abide by Largo Elite Track Club “Code of Conduct”, and I do agree to its terms and conditions.