Athlete Information Last Name First Name (Middle) Street Address Street Address Line 2 City State Zip Code Phone Number Phone(Other) Date of Birth Age Gender M F Uniform Sizing Shirt Sizes Youth Sizes: YXS Youth Sizes: YS Youth Sizes: YM Youth Sizes: YL Adult Sizes: AXS Adult Sizes: AS Adult Sizes: AM Adult Sizes: YL Adult Sizes: YXL Pant Sizes Youth Sizes: YXS Youth Sizes: YS Youth Sizes: YM Youth Sizes: YL Adult Sizes: AXS Adult Sizes: AS Adult Sizes: AM Adult Sizes: YL Adult Sizes: YXL Please Attach a copy of Birth Certificate (10 MB Max) Parent/Guardian 1 Name Parent/Guardian 1 Relationship Parent Guardian Email 1: Street Address Street Address City State Zip Code Main Phone Other Phone Alternate Parent/Guardian Emergency Contact Information Information: Parent/Guardian 2 Name Parent/Guardian 2 Relationship Parent Guardian Email 2: Street Address Line 2 Street Address Line 2 State City Zip Code Main Phone Other Phone Medical Information Primary Care Physician: Phone Medical Insurance Provider Medical Issues/Concerns: Allergies: LIABILITY WAIVER/MEDICAL TREATMENT AUTHORIZATION REGISTRATION FEES: $180.00 ALL FEES ARE NON-REFUNDABLEE Certify I, The Above Athlete and Signing Parent/and or Guardian understand and accept with the Space City Summer Track Program. I/WE release Space City, its owners, coaches, and Staff of any responsibility for any unforseen illnesses and/or injuries incurred by the athlete during the 2023 track season. In any event of an emergency Space City Track and Field has my permission to seek and obtain medical assistance as deemed necessary. By Accepting this Waiver, both the Athlete and Parent or Guardian accept in full this statement on the date of the submission of this registration form. Send
