Thimsha Registration Form
13065-1/2 Weidner St, Pacoima, CA 91331

Participant/Parents Info
First Name    Last Name    Middle Initial 

Address    City 

State    Zip Code    Phone    Email 

I hereby authorize Thimsha Track Club, it's staff, coaches, and parents to act for me according to his/her best interest in an emergency regarding medical attention. I hereby release and discharge Thimsha Track Club, its staff, coaches, parents and affiliates entities from all claims, damages, losses, personal injures and expenses. Whether in contact, tort or otherwise, actual or alleged, arising out of or in connection with application to and participation in the league.
 

Emergency/Medical Info

I understand that emergency information is required, and I will notify Thimsha Track Club of any changes. In case you are unable to reach me during any emergency, you are authorized to contact, release and if necessary transport my child to any of the following:

Do you live with : Mother Stepmother Father Stepfather Both Parents Other

Mother   Work Phone 
Father    Work Phone 
Is your child on regular medication?  yes   no
If yes please explain:


Name    Address    Phone 
Name    Address    Phone 
Name    Address    Phone 


Is there another member of the family enrolled in Thimsha Track Club:  yes   no
If yes, give name and relationship:



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