TEAM KELLY WHITE TRIATHLON TRAINING PROGRAM APPLICATION

Name:                _____________________________________

Address:            _____________________________________

                           _____________________________________

Birth Date:          _____________________________________

Home Phone:      _____________________________________

Cell Phone:         _____________________________________

E-Mail Address:  _____________________________________

Are there any health concerns Kelly should be aware of?

Are there any medications you are taking that Kelly needs to be aware of?

List three emergency contacts:

Name: _____________________________ Phone: __________________________

Name: _____________________________ Phone: __________________________

Name: _____________________________ Phone: __________________________

I enter into this triathlon-training program with the understanding that I do so in good physical health.  By signing this application I fully indemnify the facilitator of this program et all, including, but not limited to, any parties involved.  I furthermore understand all fees are due and payable upon completion of this application.  These fees are non-refundable and non-transferable.

Signature: ___________________________ Date: ________________________

Mail and make checks payable to:

Kelly White P.O. Box 55, La Mesa 91944. Include insurance release form.