Name (please print) _____________________________________
Address ____________________________________________
City State Zip Code ___________________________________________________
Gender ________
Date of Birth (MM-DD-YYYY) ________ Age _______
US Citizen? If not, country of citizenship _________________
Phone __ __ __ - __ __ __ - __ __ __ __
Club Number: 40-0097 Club: Cedar Rapids Track Club
E-Mail __________________________________________
Please circle all applicable: Cross Country Ultra-marathon Mountain/Trail Race Walking Track Field Long Distance/Road
Running
Please circle all applicable: Athlete (AT), Parent (PA), Disabled Athlete (DA) Coach: uncertified (CH), Developmental
Certified (CD), Level 1 (C1), Level 2 (C2), Level 3 (C3): Official: Uncertified (OF), Association Cert. (OA), National Cert
(ON), Master Cert (OM): Administrator (AD).
By signature below, I, a prospective member of USA Track & Field, agree to abide by the applicable USATF Bylaws, Operating
Regulations, and Competition Rules for my level(s) and category(ies) of membership.
_____________________________________________________________
Signature (if an athlete is under age 18, parent or guardian must sign)
Date of Application (MM-DD-YYYY) ____________________
