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Edinboro CORE Mini Triathlon Participant Registration and Health History Form

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  • Edinboro CORE Mini Triathlon Participant Registration and Health History Form
 

Edinboro CORE Mini Triathlon Participant Registration Information

Registration Fee: $15 Student, $25 Non-Student/Adult, $30 Student Teams, $40 Adult Teams.

*Pre-Registration Deadline: Wednesday, April 10, 2013*

*Late Registration: After April 10, add $10 to Registration Fee above and $15 ot Event Day Registration*)

Click here to pay your conference registration online with a credit card: 

http://edinborotickets.universitytickets.com/user_pages/event_listings.asp

Please make checks payable to: EUSGA Inc.

Send to:
Attention - Dave Goodwill
405 Scotland Road
Edinboro University of PA
Edinboro, PA 16444

(Participants must present some form of identification on the day of event when registering)

Maximum Particpants: 200 Athletes

Race Address:
455 Scotland Road
Edinboro, PA 16444

Questions/Concerns? Contact Dave Goodwill: dgoodwill@edinboro.edu or 814-732-1455

Edinboro CORE Mini Triathlon Participant Registration Form

(*) denotes required information.
* Division Selection (Participants must present some form of identification on the day of event when registering):

* Estimated Swim Time for 400yd Swim:

* Event Selection:

Team Memebers Names:

* Participant Legal First Name:
* Participant Legal Last Name:
* Date of Birth (MM/DD/YYYY):
* Gender:
* Address:
* City:
* State:
* Zip:
* Phone:
* Email:
* In Case of Emergency Contact:
* Emergency Contact Relationship:
* Emergency Contact Home Phone:
* Emergency Contact Work Phone:
* Emergency Contact Cell Phone:
* Do you have medical insurance?

If yes, list your Medical Provider and Privacy #:

*  Do you have any physical disabilities
or conditioins that might limit your participation?

If yes, please explain:

* Do you regularly take or need to carry medications?

If yes, Please explain:

* Have you had any operations, fractures,
bad sprains, or major illnesses during the past year?

If yes, list and explain any current condition:

* Have you ever been stung by a bee or wasp?
* Do you have any allergies?
(bees, wasps, food, medication, pollen, etc.)

If yes, identify the allergy and explain your reaction:

Early Registration (Long Sleeve Shirt Included):
Late Registration (Long Sleeve Shirt NOT Included):
* Total Amount Enclosed $
* T-Shirt Size:

Comments/Questions/Concerns: