Download 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 midSeptember, 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 postdated 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
Time
Date Set
Run Personal Bests:
Distance
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.
____Registration form initialled and signed.
____Payment received (Pay Pal, cheques)
___Fundraising bond cheque received.