GREATER MEDINA TRACK CLUB PARTICIPANT RELEASE FORM

The undersigned is registering individually or as the parent/legal guardian of a minor, child or both. As used on registration form, registrant is an adult registering for an activity individually or as a parent/legal guardian of a minor, child or both.

I recognize the possibility of physical injury associated with the participation in the Greater Medina Track Club, Inc. and the use of the Medina Senior High School track facility. I hereby assume any RISKS and release, discharge and otherwise indemnify the Greater Medina Track Club, its officers, Medina City School District and the Medina Athletic Boosters against any claim for injuries received by the registrant {and/or minor(s)} as a result of participation in the Greater Medina Track Club, Inc., use of the Medina Track facility or during transportation to or from practice/competition.

The undersigned hereby gives consent for participation in the Greater Medina Track Club, Inc. In addition, the undersigned gives consent for emergency care prescribed by a duly licensed physician or dentist. This care may be given under whatever circumstances necessary to preserve the life, limb or well being of the registrant and or minor(s). In addition, all participants must have medical health insurance and must be in good physical fitness and health.

Print Name of Parent/Legal Guardian:
Relationship to Minor:
Address:
Email Address:
Phone:
Medical Doctor:
Emergency Phone:
Contact:
Medical Insurance Policy #
Signature (must be 18 years old):
______________________________________________________________
Date:
________/____/________