fitami Athlete Application

							                                                    FitAmI
                                               APPLICANT INFORMATION
Athlete Name:
Date of Birth:                             Sex:                                        Home Phone:
Current Address:
City:                                      State:                                      Zip Code:
Email:                                     Cell Phone:

                                                  PARENT INFORMATION
Parents:
Address (if different from above):

Home Phone:                                Email:
Cell Phone:                                Email 2:
Cell Phone 2:
                                                  EMERGENCY CONTACT
Name of relative not residing with you:
Address:
City:                                      State:                                      Zip Code:
Relationship:

                                                  MEDICAL INFORMATION
Athlete known allergies and/or other medical conditions:


Doctor's Name:                             Phone Number:                               Hospital:

                                                  WAIVER INFORMATION
The waiver of liability is executed in regard to my son/daughter's participation in activity involving fitami, and/or Coach
Kevin Dilworth. I understand that my son/daughter is not required to participate in these activities. I understand that there
are certain risks associated by participating in sports activities. I will not hold fitami Coach Kevin Dilworth "responsible" for
any injuries , which may occur, as a result of my son/daughter's participation. My son/daughter has no physical
limitations, which will prevent him/her from participating. I acknowledge that we have read the forgoing WAIVER OF
LIABILITY, we understand completely, and agree not to hold fitami and/or Coach Kevin Dilworth, responsible for any
injuries that may result from my son/daughter's participation.

                                                        SIGNATURES
I declare the above information provided on this form to be true and correct.

Signature of Athlete Applicant:                                                        Date:

Signature of Parent of Athlete:                                                        Date: