jeremy mosher

Athlete Name *

First Name

Last Name

Athlete DOB *

MM

DD

YYYY

Athlete Phone #

(###)

###

####

Parent / Guardian or Emergency Contact *

First Name

Last Name

Guardian / Emergency Contact Phone # *

(###)

###

####

Acknowledgement of Participation and Risk / Waiver and Release of Liability *

I acknowledge my/my child's participation in activities with the Park Hills Athletic Club (USATF #41-8992), and hereby release, waive and covenant not to sue, and further agree to indemnify, defend and hold harmless the club or its officers (official or designated) with respect to any liability, claim(s), demand(s), cause(s) of action, damage(s), loss or expense (including court costs and attorneys’ fees) of any kind or nature (“Liability”) which may arise out of, result from, or relate in any way to my participation with Park Hills Athletic Club, except to the extent caused by the gross negligence and/or willful misconduct of any of the Released Parties.

Read, agreed, and signed

Start-Up Dues *

Athletes are not required to buy a Park Hills Athletic Club jersey to participate in most events, but HS athletes cannot wear ANY school-branded items in competition. (Competing on a team in national or national-qualifying meets will require a PHAC uniform.)

$25 = membership only < < INCLUDES ENTRY TO FIRST MEET

$80 = membership + uniform top

Additional P.H.A.C. Apparel

$30 = short-sleeve tech-top

$44 = long-sleeve tech-top

$38 = jacket

Payment Agreement (memo: PHAC) *

Venmo @Jeremy-Mosher-1

check payable to "Jeremy Mosher"