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 KANSAS CITY COUGARS TRACK CLUB
3003 N. Getty
Kansas City, KS 66104
Telephone: (913) 944-0119
Email: cougarstrack@hotmail.com
2008 Membership Form
(Please print)
Instructions: To complete membership process: 1) Print and complete form 2) copy of birth certificate, 3) copy of 2008 AAU Card and 4) Fee and 5) Uniform Fees. See below details of membership fees. A form must be completed for each child. Turn in the paperwork to Coach Rollins at Washington High School.
Today's Date:_______________________
Last Name, Middle, First Name_______________________________________________________________
Age:________ Date of Birth: _______/________/______ Male � Female �
Address:_______________________________City_______________State_________Zip Code_________
Home/Work Phone:______________________________________________________________
Cell Phone1/Cell Phone 2:________________________________________________________
*Email Address:________________________________________________________________
Mother's Name:_____________________________________Tel/Cell1_____________________________
Father's Name: _____________________________________Tel/Cell1____________________________
Emergency Contact Name and Phone:________________________________________________________
Family Physician:_____________________________________________Phone_______________________
Allergies/Physical/Medical Concerns:_________________________________________________________
Last Tetanus Shot:__________________Health Insurance Company:_______________________________
Release
I/we acknowledge that the above named participant is physically fit and does not have any health or medical conditions
that would prevent the name participant from participating in any track and field events. I/ we further agree to hold harmless
the KC Cougars Track Team/Club and USD#500, its agents,coaches, employees, volunteers, or representative for any
injury, damage, or accident suffered in connection with the track and field program. I/we have read, understand, and accept this waiver of liability.
Parent/Guardian Name (Please Print)______________________________________________________________
Parent/Guardian Signature:_____________________________________________________________________
How did you hear about the KCCougars Track Club?
� Word of Mouth
� I was a member last year
� A current member told me about the club - Member's Name:____________________________________
� Publicity - Radio, Flyers, etc...
� Other________________________________________________________________________________
* IMPORTANT: Coach Rollins will communicate and distribute information about the club via email. It is important to check your email frequently to be aware of any upcoming track meets, meetings, etc... that may involve your child, you or the club.
2008 MEMBERSHIP COSTS: FOR OFFICE USE ONLY
$5 Non-Refundable Administrative Fee � $5 Non-Refundable Administrative Fee
$12 2008 AAU Card (required to particpate) � $35 Uniforms Fee or Deposit (Sweat Siuts) A mount Paid $______
$35 Uniform Fee (Shorts/Top) (If applicable) � Copy of 2008 AAU Card
$60 Sweat Suits/$ 30 deposit required by May 17, 2008 � Copy of Birth Certificate
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