Medical Insurance_________________________________________ ID/Policy #___________________________
I understand that the Team Onalysis Track Club does not assume responsibility for payment of a physician in any case. However, in an emergency the Team Onalysis Track Club may choose a physician/hospital.
Name of Preferred Doctor_______________________________________________ Phone________________________
Name of Preferred Hospital______________________________________________ Phone________________________
Is your child allergic to any medication? Yes________ No________ If yes, what__________________________ foods? Yes________ No________ If yes, what___________________________
Does your child have any chronic illness? (Asthma, diabetes, heart disease, epilepsy)
If yes, what___________________________________________________________________
Does your child take any medicines on a regular basis? Yes______ No______
If yes, what and what for? List: _____________________________________________________________
Shirt (circle one) YS, YM, YL, XSM, S, M, L, XL
Shorts (circle one) YS, YM, YL, XSM, S, M, L, XL
Waiver and Agreement
For and in consideration of the benefits accruing to my child as a result of the sponsorships of the Team Onalysis Track Club the adequacy and sufficiency of which considerations is hereby acknowledged, I do hereby waiver and release any and all rights and claims for damages which may accrue in my favor against the Team Onalysis Track Club, and their respective officers, agents, and sustain in any manner whatsoever arising out of or in any ways connected with the Team Onalysis Track Club.