Manitoba Youth Team Program Registration Form

MANITOBA TRIATHLON CENTRE (MTC) – 2016-2017 Registration Form

Athlete Name: ______Tri MB Member #: ______

Mailing Address: ______

Phone: (h)______(w)______(c)______

Email Address(es):______

Birthdate: ______Medical Number (6 digit)______

PHIN (9 digit)______

Parent/Guardian Name(s): ______

Phone: (h)______(w)______(c)______

Email Address: ______

Athlete Medical Concerns Coach Should Be Aware of: Include any allergies or medications.

______

CONSENT FOR EMERGENCY MEDICAL TREATMENT

I, ______, give permission to the MTC coaches to make decisions concerning medical care and treatment, and where necessary to authorize such care and treatment in emergency situations. I hereby give my permission to the licensed physician, dentist, athletic therapist, nurse or other medical professional whose services might be required to provide medical care and treatment.

______Printed Name of Athlete Signature of Athlete Date

______Printed Name of Parent or Guardian Signature of Parent or Guardian Date (If Athlete is under 18 years of age)

Emergency Contacts:

#1 ______name relationship home phone cell phone

#2 ______name relationship home phone cell phone Fee Structure

MTC offers an 11 month program which runs from mid-October to mid- September, although new athletes may join at any time. Fees can be paid in one lump sum at the beginning of the year or in four equal installments on Oct 24, Dec 15, Feb 15 and Apr 15. (please mark the program you are enrolling in)

______Developmental (Part time) $1045 or 4 x $265 (equals $95/month of training)

______Development Cross Training (Part time, no swimming) $825 or 4 x $206.25 (equals $75/month of training)

______Bridging Program between Developmental and High Performance, invitation only by Head Coach. $150.00/month

______High Performance (Full time) $1925 or 4 x $490 (equals $175/month of training) (HP Athletes will be required to purchase a U of M Facility Pass)

** New for 2016-17 – Satellite MTC Training Program – for athletes living outside of Winnipeg wishing to receive customized online training from the Head Coach. Arrangements will be made throughout the year for athlete(s) and coach to get together for time trials, clinics, camps, and events.

______Satellite Training Program $50.00/month

To withdraw from the program, 30 days written notice is required. Fees will be prorated accordingly. There will be a $25.00 administration fee.

Payment Options:

- Cheques made payable to Triathlon Manitoba. - Credit card processed through Pay Pal. ** A Pay Pal service charge of 3% will be added to the program fee. **

Fundraising:

In order for Triathlon Manitoba to deliver a high quality triathlon program, each participant is required to fundraise throughout the year. All monies raised will help support facility fees and training camps. A fundraising bond cheque post- dated to June 30 2017 in the amount of $200.00 made payable to Triathlon Manitoba is required at time of registration. The cheque will only be cashed in the event that a participant does not meet the fundraising requirements.

Please initial that you have read and accept the fee structure, payment options, and fundraising obligation for the MTC program ______. Athlete Information: Swim Personal Bests: Distance Time Date Set

Run Personal Bests: Distance Time Date Set

Bike Time Trials, Mountain Bike or other race results: Type of Bike you own (if any:______) Distance Time Date Set

Current Club:______Current Sport: ______Current Coach: ______Coach’s Phone Number: ______

Sporting History: Include best results in past 24 months

Current Training Status: (indicate current typical training week)

What are your personal goals for this training year?

What personality traits or abilities do you believe you will add to the team? AWARENESS AND ACKNOWLEDGEMENT OF RISKS

In consideration of my participation in such programs, activities and events, I hereby acknowledge that I am aware of the risks and hazards associated with or related to the sports of triathlon and all related activities that may result in personal injury, death, property damage, expense and related loss. The risks and hazards of triathlon include, but are not limited to injuries as a result of:  Entering the water by either diving, running or jumping;  Spending extended times in pools or lakes including bacterial infections and rashes;  Physical contact with other participants while swimming including crowding, pushing, kicking and punching;  Water conditions such as currents, waves, water temperature and water clarity;  Physical contact with pool walls or lake and ocean rocks and bottoms;  Physical contact with other participants while cycling and running;  Road conditions, terrains and vehicular traffic while cycling and running;  Falling while cycling or running;  Strenuous cardiovascular workouts, and/or exerting and stretching various muscle groups;  Psychological factors such as anxiety;  Changing weather conditions;  Dehydration and/or fatigue; and  Negligence of other participants.

BY SUBMITTING THIS ENTRY, I AGREE TO BE RESPONSIBLE FOR MYSELF. I am participating voluntarily in these activities, events and programs. I agree that there are risks in triathlon as described above.

If something happens to me, I release the organizers of responsibility for any claims, demands, actions and costs, which might arise, out of my participation. In this Agreement I understand “organizers” to mean: the Manitoba Training Centre, Triathlon Manitoba, its directors, officers, members, employees, volunteers, officials, race directors/organizers, participants, clubs, agents, sponsors, funding partners, owners/operators of the facility, and representatives.

I further acknowledge and understand that insurance coverage for this program does not provide me with personal accident insurance coverage and that I am responsible to obtain my own personal accident insurance coverage should I wish that I be eligible for accident benefits that are in excess of those currently covered through my provincial or private health insurance plan(s).

I ACKNOWLEDGE MAKING THIS AGREEMENT. I have read and understood the terms and conditions of this agreement, and by signing it voluntarily, I am agreeing to abide by these terms.

______Printed Name of Athlete Signature of Athlete Date

______Printed Name of Parent or Guardian Signature of Parent or Guardian Date (If Athlete is under 18 years of age)

For Office Use Only: ____Registration form completed in full. ___Fundraising bond cheque received. ____Registration form initialled and signed. ____Payment received (Pay Pal, cheques)