Track Emergency Contact Form

indicates a required answer

1. *	Participants Name

2. *	Parents Name

3. *	Parents Phone Number

4. *

Emergency Contact

(If unable to reach parent/guardian)

5. *

Emergency Contact Phone Number

(If unable to reach the parent or guardian)

6. *

Medical Conditions

(Please list any and all medical conditions.)

Allergies

(Please list all allergies. If no allergies, please add "No Known Allergies")

8. *

The above named student and parent/guardian have requested registra-
tion of the student in the IGNITED Track Meet.

In consideration of such registration, the right of the student to compete in the IGNITED Track
Meet, and the use by the student of the sponsoring agency’s facilities
and equipment, both the student and parent/guardian each
acknowledge that the student will be competing at his/her own risk and
release and hold harmless the sponsoring agency, IGNITED Homeschool Group.

We also agree to allow IGNITED to use the students name, like-
ness, and information concerning the student in reporting the results of competition.

We certify that the information on this entry for is correct.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.