cornerstoneathletics@yahoo.

com
678-296-7077 or 678-768-9828
MEMBER REGISTRATION
NAME:

BIRTHDAY:

SCHOOL:

GRADE:

AGE:

PARENTS/GUARDIANS
ADDRESS:
City

TELEPHONE #s:

State

Zip

EMAIL:

U.S. CITIZEN?

COUNTRY OF CITIZENSHIP, if not U.S.

PASSPORT/VISA/GREEN CARD #

In Case of an Emergency Notify:

NAME:

PHONE #:

Parents please indicate yes/no and initial:

Yes/No

Initial

___

___

I am interested in / willing to serve as a volunteer, as needed.

____

____

I understand and give permission for photos & videos to be taken of my child. (These items
will be used to highlight my childs achievements and to promote the Cornerstone Track and
Athletic Association, Inc. through the organizations website, media, social media, and
presentations.)

Parent/Guardian Signature

Printed Name

Date

Student-Athletes please check all that apply:

I have participated in track and field before
I am interested in competing in local track meets
I have / currently participate in other sports. List: _____________________________
I plan to participate in other sports. List: ____________________________________
I WILL do my best to always strive to meet my maximum potential, be respectful and considerate to
others, and be positive and encouraging to my teammates, exercising good sportsmanship at all times.
Student-Athlete Signature

Printed Name

Date

www.cornerstonetrackandathletics.org
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HEALTH INFORMATION
The following information will remain confidential to the program leaders, designated person (s) trained
in first aid or emergency personnel as need.
Please indicate if your child has any of the following types of allergies:
Food (s)::
Medicine (s):
Other:
Name of primary care physician:
Address::
Please list any restrictions on physical activity and other health conditions that would be beneficial in
ensuring that your child receives appropriate care in case the need arises:

The health history provided above is complete and accurate. I know of no reason(s), except what has
been indicated on this form, why my child should not participate in any track and field activities. I
hereby give permission to the program leaders to administer basic first aid as need and/or to seek
emergency medical treatment and arrange for related transportation for my child, as needed.
Please submit a copy of the student-athletes sports physical and birth certificate.

Parent/Guardian Signature

Printed Name

Date

T-Shirt/Uniform Sizes
Youth: X-Small - Small Medium Large

T-Shirt Size:

Adult: Small Medium Large X-Large 2X-Large Other ________

Uniform Sizes:

Top:_______________

Shorts:_______________

We would appreciate a minimum payment of 1/3 of your total cost at the time of application.
(We offer installment payments and sibling discounts.)
FOR AGENCY USE:
____ Birth certificate

____ Fee Sheet

____ Signatures/Initials

____ Sports Physical

____ Waiver

____ Form Completed

www.cornerstonetrackandathletics.org
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