FFTC  2010         Athlete Registration Form

Athlete’s Name (Last) ______________(MI) ___(First__________________
Street Address____________________________________________________
City _____________   Zip __________ Home Phone____________________

Date of Birth ______/______/_____  Male ____Female __Current Age____

Current  School  _______________________________________________

Cell Phone ____________Family E-Mail Address ____________________

Parent/Guardian ________________  Relationship ___________________

Address (if different)__________________________________________

Home Phone (if different) _____________ Work Phone ______________

Email Address (if different from above) _____________________________

Emergency Contact Name ________________________Phone__________

Financial Information:   Fees are $85.00 for the 1^st child, $65.00 for the second child, three or more children family plan.  Uniform deposit will be $15.00 refundable at the end of season, when uniform is returned in good condition.  There is a reduced season fee (end of school district season) for high school athletes that register before May 31^st for the 2010 season.  Fee payment must be made no later than the first day of practice. 

A copy of your athlete’s birth certificate, picture and insurance card must accompany this application.

                          (If athlete was a member last season, birth certificate will be on file)

Waiver: In consideration of your accepting this application, I do hereby, for myself, my heirs, executors, administrators, waive, release and forever discharge any and all rights and claims to me against the FAST FORWARD TRAK CLUB,  its officers, directors, volunteers, sponsors, coaches and others aiding in the program, etc. and/or assigns for any and all damages which may be sustained and suffered in connection with said association or entry and/or arising out of traveling to or participating in and returning from practices and meets. It is expressly understood by the undersigned that he/she is solely responsible for any costs arising out of any bodily injury or property damage sustained through participation in normal or unusual activities of this program. The undersigned also understands that a part of their registration fee covers the Amateur Athletic Union insurance card for their participation.

I HEREBY AUTHORIZE ANY REGISTERED PHYSICIAN OR LICENSED HOSPITAL TO PERFORM ANY TREATMENT THEY JUDGE NECESSARY IN AN EMERGENCY IF I AM UNABLE TO BE REACHED BY PHONE.

I HAVE CAREFULLY READ AND UNDERSTAND COMPLETELY AND CLEARLY THE ABOVE PROVISIONS AND AGREE TO BE BOUND BY THEM.

__________________________________                                             ________________________________

Authorized Parent (please print)                               Authorized Parent Signature

Date: ___________________

STATE OF FLORIDA
COUNTY OF ____________________

The foregoing instrument was acknowledged before me this _____day of ______, 20___, by:

Personally Known _______ OR Produced Identification _______
Type of Identification Produced __________________________

Please Check One:

T-Shirt Size

__________ Youth Small                                             __________ Adult Small

__________ Youth Medium                                         __________ Adult Medium

__________ Youth Large                                            __________ Adult Large

                                                                                    __________ Adult X-Large

Please list any known allergies or medication being taken:

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