Mercury Running Club Information Form

Because of insurance and liability requirements, membership in the Mercury Running Club and USATF is required for all athletes who wish to practice or compete with the team.

You must complete this and all other team forms before you can practice or compete with the team. Upon completion of this form, you must give it and a copy of the birth certificate to Coach Pappadakis before you begin your first practice or competition.

Year: ______(Check one) XC Regular Season : ___ XC Post Season: ___Track Regular Season ___

Track Post Season ___ Elite XC or Track ____ Summer Conditioning ____ Summer Camp ___

(Print Neatly)Athlete’s Name ______USATF Number______

Grade:______D.O.B. ______Gender______Athlete’s Cell Phone (____)______

School______Event Preference (Track & Field)______

Parent/Guardian’s Name ______Cell Phone (____)______

Parent/Guardian’s Name ______Cell Phone (____)______

Email (Parent/Guardian) 1.______2.______

Email (Athlete)______Athlete’s T-shirt size ______

PERSON (OTHER THAN PARENT) TO NOTIFY IN CASE OF EMERGENCY:

Name______Relationship: ______Phone (____)______

Family Physician ______Phone (______)______

Medical Plan ______Plan Number______

Does your child wear contact lenses/glasses ______Hearing aid______have Asthma_____ what medication______

Does your child take any medication on a regular basis _____list the specific medication ______

Does your child have any allergies ______to what ______

In consideration of your allowing the above-named athlete to practice and/or compete with THE MERCURY RUNNING CLUB, I/We, intending to be legally bound for myself/ourselves and my/our heirs, executors and administrators do hereby waive and release forever any and all rights and claims for damages I/We may accrue against THE MERCURY RUNNING CLUB, the San Jose Unified School District, the City of Campbell/San Jose, and any other person, organization or officials affiliated with THE MERCURY RUNNING CLUB as well as their representatives, successors and assigns, for any and all injuries arising from any participation in and/or traveling to or from THE MERCURY RUNNING CLUB outings, practices, and/or meets. In the event we cannot be reached in an emergency, I/We hereby give permission for: Cliff Pappadakis, or any other Mercury Running Club Coach or official to authorize by his /her signature whatever medical treatment may be considered necessary by the attending physician for my/our child. (PHOTO RELEASE) By signing this form I also hereby release all rights and grant full permission to THE MERCURY RUNNING CLUB to use any photographs, motion pictures, recordings or any other record of my participation in this program for any legitimate purpose, including commercial advertising.

Parent/Guardian’s Signature ______Date ______

Parent/Guardian’s Signature ______Date ______

Athlete’s Signature (if over 18) ______Date ______

Team website:

5-22-16