Hillsborough County Parks, Recreation and Conservation Department
2014 Athletics Enrollment Form
Track Club
Enrollment Form, Medical Information, and Parental Permission Form for Athletes
Signature on this form indicates that the athlete and parent(s) or guardian(s) agree to abide by the athletic policies of Hillsborough County Parks and Recreation, Phase 1 Track Club, and the AAU/USA TF Organizations.
Athlete Information
Athlete’s Name______________________________________DOB (month/day/yr)__________________
Address____________________________________________City______________State____Zip________
Name of School, Sport(s) & position____________________________________________________________
Broken Bone(s)-Date(s)____________________________________________________________________
Recent Head Injury-Date(s)________________________________________________________________
Last Tetanus Shot-Date(s)________________________________Date of last physical exam___________
Do you have any physical health problems or restrictions? If yes, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
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Are you currently taking any medications? If yes, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have any allergies? If yes, please explain and provide the name of the allergy medication you take.______________________________________________________________________________________
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I am aware that playing or practicing in any sport can be dangerous in nature involving MANY RISKS OR INJURY-major or minor. Because of the dangers of participating in sports, I recognize the importance of following coach’s instructions regarding playing techniques, training, and other team rules and agree to obey such instructions.
__________________________________________________________________________________________
Athletes Name Athletes Signature Date
Permission & Treatment
In case of injury during practice or competition, I hereby consent to have the above names athlete examined and if required to be treated by a physician or hospital. I am of the understanding that in case of injury, Phase 1 Track Club will make every effort to contact me prior to taking my child to a physician or hospital. In the event I cannot be reached, Phase 1 Track Club
& its representatives have my permission to take appropriate steps to insure the safety and well-being of my child.
Liability
I, as the parent/guardian for the above named athlete, do hereby give full permission for him/her to participate in practices and competition for HCPRCD youth team activities sponsored and conducted by the HCPRCD Athletic section. As parent/guardian, I hereby release, discharge and hold harmless Hillsborough County & Phase 1 Track Club of any and all liability connected with our child’s participation and I assume full responsibility in the event of accident/injury before, during, and after practices and competition.
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Parent/Guardian Name Parent/Guardian Signature Date
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Home Address (including the City, State, & Zip Code)
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Home Phone Mother’s Name & Cell Father’s Name & Cell
__________________________________________________________________________________________
Email Addresses where you would like to be notified of upcoming events and important information
Office Use Only: 2014 AAU#__________ Reg. fee paid on: _______ by Cash/Check/MC/Visa/Amex/Disc
OTOG…”One Team One Goal”