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.
(Check) XC: ___ Track___ Summer ____ Satallite/Off Campus ______Year: ______
(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: http://sjusd.org/willow-glen-middle/teachers/pappadakis-cliff/running-club-joining-the-team/24095
9-29-15