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Dynasty TC Membership Form Step 1 of 6 0% Parent/Guardian #1: Name* First Last Email* Phone*Alternate PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Guardian #2: Name First Last Email PhoneAlternate PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Student Athlete: Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email PhoneBirth Date* Date Format: MM slash DD slash YYYY Shirt Sizes* XXL XL L M S XS Emergency Contacts #1 : Full Name* First Last Relationship*Primary Phone Number*Alternate Phone NumberEmergency Contacts #2 : Full Name* First Last Relationship*Primary Phone Number*Alternate Phone Number AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENTMy child has the following health concerns, problems, and/or issues:*He / She is taking the following medications:*He / She is allergic to the following medications:*Important notes related to emergency treatment:*Permission checkbox* In case of illness or accident, I, give my permission for the emergency medical treatment of my child, if I cannot first be contacted. I understand that I am responsible for all costs associated with the treatment of my child.* Media Wavier* Dynasty Track Club Photo/Media Release Form By signing below, I, parent or legal guardian of (minor child/athlete) understand and agree that Dynasty Track Club (DTC) has my permission to take and use my child’s track and field/club photographs, digital images, and video images for official Club purposes such as, but not limited to media press releases, social media posts, and the club newsletter. Furthermore, I understand that by signing below I consent to the organization’s right to publish photographs depicting the minor athlete/child named above engaged in track and field events of Dynasty Track Club, whether as an active participant or as an observer, on the official Dynasty Track Club website found at the web address: www.DynastyTrackGA.org. I have fully read and considered all the terms and statements contained in this release before affixing my signature. I have read, understood, and accepted the media wavier. By clicking the Submit button, I agree to the terms of the Media Wavier. Liability Wavier* Dynasty Track ClubPARENT/GUARDIAN LIABILITY WAIVER FORM This Liability Waiver Form must be completed and signed by the parent or guardian for each athlete before participation in any Dynasty Track Club athletic practice, activity, event, or meet. FOR AND IN CONSIDERATION OF the mutual promises, covenants, conditions, representations, and warranties contained herein, and for other good and valuable consideration, the receipt and legal sufficiency of which are hereby acknowledged, it is agreed as follows: I am the parent/legal guardian. By my signature I hereby give my consent for the above-named child to participate in practices, track meets, road races, travel, and other activities sanctioned, sponsored, and/or attended by Dynasty Track Club (DTC). I authorize the Head Coach, Coaches or Staff members to sign the standard athlete’s release forms, CCYTL, GRPA, USA Track & Field (USATF) documents when entering my child in any sanctioned events. Should I (or my child) decide to withdraw from participation with Dynasty Track Club and its activities, I agree to notify DTC in writing or email, that I am withdrawing the above-named child and acknowledge that all REGISTRATION FEES PAID ARE NONREFUNDABLE. The undersigned hereby releases and forever discharges the Dynasty Track Club (DTC) and all of its Board Members, officers, coaches, and attorneys, from any and all claims, demands, actions, causes of action or suits arising out of any injuries, known or unknown, which have resulted or may in the future result from any DTC sponsored athletic practice, activity, event or meet. The signee below represents that the above-named child’s Medical History including allergies, medications being taken and physical impairments that will in any way effect the child’s participation have been brought to the attention of Dynasty Track Club in writing on the Medical Acknowledgement/Waiver/Consent and Release form of Dynasty Track Club. I understand my child will not be covered by insurance provided by Dynasty Track Club and that I either have my own major Medical Insurance Policy or, if not; I will cover the expenses of any injury. The undersigned hereby assumes all risk of injury associated with any such athletic practice, activity, event or meet and fully indemnifies and holds harmless DTC along with its Board Members, officers, coaches, and attorneys from and against each and every liability, loss, cost, damage, and expense, including attorney’s fees, which DTC along with its Board Members, officers, coaches, and attorneys may incur as a result of any DTC sponsored athletic practice, activity, event or meet. This liability waiver/release applies to the following athlete. I have read, understood, and accepted the liability wavier for membership. By clicking the Submit button, I agree to the terms of the Liability Wavier. Club Rules*Dynasty Track Club Rules & Code of Ethics ATHLETES 1. Do your best to make every practice and be on time. 2. Arrive at practice ready to listen, work hard, and learn. 3. Be supportive of all athletes on your team. 4. Show respect for coaches, officials, teammates, and opponents. 5. Learn the rules and always compete by them. 6. Use only appropriate language around club events. 7. Athletes do not leave the premises of track meets (even with parents) without informing a coach/team mom. 8. ABSOLUTELY NO drugs or alcoholic beverages are to be in the possession of any team member at any time. 9. Athletes will compete in the designated DTC’s uniform unless prior approval is received from the coaches. PARENTS 1. Parents, coaches, adult volunteers, and friends of DTC must be role models for children by conducting themselves as responsible, moral, ethical adults worthy of the respect and emulation of children. 2. Parents are responsible for providing transportation for their children to and from practice to insure safety and protection. Parents are responsible for getting their children to practice and picking them up from practice on time. Coaches will NOT leave the premises of the track until ALL children are accounted for. 3. Parents are not permitted on the track or in practice areas during practice or meets. 4. Support coaches and officials. Parental interference with coaching will not be tolerated. Parents may discuss their athletes training/coaching program with coaches following practice. 5. Parents are to inform the coach of any special needs your child may have. 6. Support the club by volunteering to help with meets and fundraising events. Any discipline issues will be referred to the entire coaching staff and may result in immediate dismissal from the club. Please note that ALL fees paid NON-REFUNDABLE if the participant is found in violation of any of the above rules. I have read the above code of conduct (for parent and child) and I agree to follow and give permission for my child to participate with Dynasty Track Club. I understand that I may withdraw my permission for my child/children’s participation at any time. PAYMENT INFORMATION Club Fee: Spring & Summer Season $475.00 Payment Method Options: Online/Team Website, Cash, or Check Return Check Policy There will be a thirty-dollar ($30) NSF fee imposed on all returned checks. NO EXCEPTIONS. I understand & acknowledge return check policy. I agree to the club rules. By clicking the Submit button, I agree to the Club Rules. Medical Release Form* Medical Acknowledgement, Consent, and Release Form for Emergency Treatment I (parent/legal guardian) acknowledge that a physician has examined, registered athlete, within one (1) year of participation in Dynasty Track Club\training and competition seasons. Furthermore, I acknowledge that said physician has certified that said athlete has been cleared to participate and complete in the various athletic activities related to track and field participation, contests, and competitions. I do hereby give my consent for the above athlete to participate in Dynasty Track & Field Program. I THE UNDERSIGNED HEREBY WAIVE AND RELEASE any and all claims I may have against Dynasty Track Club, Inc. IT'S OFFICERS, DIRECTORS, EMPLOYEES, COACHES, AND AGENTS OR ITS representatives from ANY AND ALL LIABILITY DUE TO PERSONAL INJURY RESULTING FROM ACTIVITIES SPONSORED BY DYNASTY TRACK CLUB, Inc. OR FOR WHICH DYNASTY TRACK CLUB, IS A PARTICIPANT. Moreover, I authorize the coaching staff or assigned chaperones of Dynasty Track Club to act as Spokesperson in granting permission for emergency Treatment/Hospitalization (including Anesthesia), if necessary for the afore-mentioned athlete and to make any decisions concerning the health, welfare, and safety including medical treatment of this athlete during my absence. I understand that should a Health Emergency arise, I will be notified, but if I cannot be reached by telephone, such medical treatment as deemed necessary by competent medical personnel is authorized. I agree to the medical release form. By clicking the Submit button, I agree to the Medical Release Wavier.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.