Detroit Jets Track Club

Membership Application

Membership Information

(Please Print)

Name___________________ ____________________ ___________________

Last First Middle

Address_________________ ____________________ Sex________________

Number Street M/F

Home Phone ( )___________________ Birth Date_____________________

Area Code Number Month/Day/Year

E-Mail Address (Optional)__________________________________________________

Parent/Guardian Information

Father’s Name_______________________	Home Phone______________________	Work Phone___________________
Mother’s Name_______________________	Home Phone______________________	Work Phone___________________
Guardian’s Name_______________________	Home Phone______________________	Work Phone___________________
Other Emergency __________________	Home Phone______________________	Work Phone___________________

Member’s Medical Information

List Member’s Illnesses, Physical Conditions, Allergies, etc. (For example, “Asthma”)

(If none, please write “NONE” above)

I certify and attest that the above-name Member is physically fit and able to participate in the activities of The Detroit Jets Track Club; and that his or her physical condition and ability to participate in the activities of The Detroit Jets Track Club have been determined by a licensed medical doctor. The only physical conditions illnesses, allergies, etc. which the above-named Member has stated above on this form and those physical conditions, illnesses, allergies, etc., have been determined by a licensed medical doctor to be not such as would make it dangerous or inadvisable for him or her to train, compete, or participate in the demanding physical activities of The Detroit Jets Track Club.

Father’s Signature Or Guardian’s Signature______________________ Date________________________

Mother’s Signature Or Guardian’s Signature_____________________ Date________________________