Athlete Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Athlete Cell Phone (for team snap)

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Caregiver 1 *

First Name

Last Name

Phone *

(###)

###

####

Parent/Caregiver 2

First Name

Last Name

Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Media Release *

At times images of athletes will be shared on our personal social media accounts or through the media.

Yes I consent

No I do not want images shared with the media or posted on social media

I will be paying the $375 registration fee via

e-transfer to rotaryrunningclub@gmail.com