2021 REGISTRATION APPLICATION
FIRST NAME: _______________________ MIDDLE: ______________ LAST: _____________________
GENDER: MALE or FEMALE DATE OF BIRTH: ____/_______/_____ AGE: ______
ETHNICITY: ________________ ADDRESS:____________________ CITY: _________________
NAME: ________________________________________ RELATIONSHIP: ______________________________
HOME PHONE: _____________ WORK PHONE: ______________ CELL PHONE: _______________
DOCTOR’S NAME: _______________________________
DOCTOR’S PHONE: _______________________________
PERMISSION FOR DOCTOR/HOSPITAL: ________YES ________NO
IS THIS MEMBER ON HEALTH INSURANCE/MEDICAID/CHIPS: ________YES ________NO
Insurance Provider: __________________________
PLEASE LIST ANY HEALTH CONCERNS OR MEDICAL CONDITIONS INCLUDING ALLERGIES AND FOOD ALLERGIES AND ANY MEDICATIONS, FREQUENCY USED, AND ANY OTHER NECESSARY INFORMATION REGARDING MEDICATIONS:
HEALTH CONCERNS/MEDICAL CONDITIONS: MEDICATIONS/DOSAGE:
I, _______________________________, give permission for, __________________________, to be a member of the JDIN/WAVE TRACK Program and hereby
(Parent/Legal Guardian) (Member)
give my consent for said member to participate in any and all activities including transportation to and from activities. I/We do hereby waive any claim for loss, damage, or injury and agree to hold harmless Wharton Wave Athletic Club, their Board of Directors, Just Do It Now, Inc., and any sponsors, organizers, coaches, officials, and/or Wharton Independent School District.
(Parent/Guardian Signature) (Date)
AAU Membership and up to 4 track meets is included in Wave Track Registration Fee. Additional track meets may have additional fees. Uniform jersey will be provided, but must returned after each meet.
Member will need to purchase shoes and black shorts.
PAYMENT AMT. DUE: $40 PAYMENT AMT. MADE: _________ REMAINING BALANCE: _______
METHOD OF PAYMENT: CASH or CHECK
RCVD. BY ________________ DATE RCVD: ___________ BIRTH CERT. RCVD _________ BIRTH CERT.
ALREADY ON FILE: ___________
Shirt Size: YXS YS YM YL YXL AS AM AL AXL (Circle One)