CEDAR RAPIDS TRACK CLUB 2010
SUMMER TRACK PROGRAM
USA Track & Field Membership Application
Athlete's
Name (please print)______________________________________________
Father's Name__________________________________________________________
Mother's Name__________________________________________________________
Address _______________________________________________________________
City, State Zip Code ______________________________________________________
Date of Birth (MM-DD-YYYY) ____________________
Age ________ Gender_______
US Citizen? If not, country of citizenship ____________________________
Phone __ __ __ - __ __ __ - __ __ __ __
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).
Club Number: 40-0097 Club: Cedar Rapids Track
Club
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) ____________________
