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Girls on the Run of WNC

PARTICIPANT REGISTRATION FORM Complete & return this form to your girl’s school or program site. For more information: www.gotrwnc.org, (828) 713-3132, [email protected] _________________________________________________ PROGRAM SITE/SCHOOL WHERE GIRL IS PARTICIPATING _____________________________________ PARTICIPANT FIRST NAME T-SHIRT SIZE: (please circle one) : YOUTH:

_____________________________________ PARTICIPANT LAST NAME

Medium (8-10) Large (12-14)

__________________________________________________ STREET ADDRESS 1

ADULT:

Small

_____/_____/_____ DATE OF BIRTH

Medium

Large

X-Large XXL

__________________________________________________ STREET ADDRESS 2

_________________________________________________ _______ ______________ CITY STATE ZIP CODE How many previous seasons has your daughter participated in Girls on the Run, Girls on Track, or Heart & Sole? ______ PARTICIPANT’S GRADE: _____ ETHNICITY (please circle one):

PARTICIPANT’S HOMEROOM TEACHER: ______________________________________________ African American

American Indian

Asian

Caucasian

Hispanic

Multi-Racial

Other

HEALTH INFORMATION

_____________________________________________

_____________________________________________

ALLERGIES - Do these allergies require the use of an epi-pen?

MEDICATIONS (including inhalers)

__________________________________________________________________________________________________ Any additional special mental, physical, or medical information? HOW SHOULD YOUR CHILD BE RELEASED AFTER GIRLS ON THE RUN? (please circle one) : Picked up by parent, guardian, or other authorized individual / On-site after school program / Activity or school bus / Walking

__________________________________________________________________________________________________ AUTHORIZED INDIVIDUALS FOR PICK-UP (List anyone other than legal parent(s)/guardian(s) who may be picking up participant) PARENT/GUARDIAN CONTACT INFORMATION ___________________________________________ PARENT/GUARDIAN FULL NAME

___________________ RELATIONSHIP

______________________________________________________________ PARENT/GUARDIAN EMAIL

________-________-_____________ PARENT/GUARDIAN PRIMARY PHONE ________-________-_____________ PARENT/GUARDIAN ALTERNATE PHONE

EMERGENCY CONTACT INFORMATION (must be different from parent/guardian listed on opposite page) _______________________________________ EMERGENCY CONTACT FULL NAME

_________________________ RELATIONSHIP TO PARTICIPANT

______________________________________________________________ EMERGENCY CONTACT EMAIL

________-________-_____________ EMERGENCY CONTACT PRIMARY PHONE ________-________-_____________ EMERGENCY CONTACT ALTERNATE PHONE

INSURANCE INFORMATION - Does the participant have health insurance? (please circle one) : Y / N ____________________________ INSURANCE COMPANY

____________________________ INSURANCE PLAN NAME

____________________________ SUBSCRIBER NAME

____________________________ GROUP NUMBER

____________________________ POLICY NUMBER

____________________________ REALTIONSHIP TO PARTICIPANT

REGISTRATION FEE: $150.00 Fee includes 20 lessons led by a trained coach, T-shirt, water bottle, 5K entry & medal. SLIDING SCALE PROGRAM SCHOLARHIPS: We offer our program on a sliding scale fee. GOTRWNC relies on grants, sponsors & donors to fund our program scholarships that enable all girls, regardless of income or ability, the opportunity to participate. Please CIRCLE the box below with your annual family income & household size, & use the scale to identify amount owed.

If you cannot pay the full registration fee owed today, additional payment(s) can be mailed or delivered to: GOTRWNC, 50 S. French Broad Ave. Ste 204, Asheville, NC 28801.

PERMISSIONS, RELEASES, AND PARENT/GUARDIAN SIGNATURE I am the parent or legal guardian of _________________________________________________________, a minor (“Participant”). I agree that the Participant may participate in the Girls on the Run® program. The purpose of the program is to increase the Participant’s activity/fitness level and self-esteem while at the same time teaching life skills that will be beneficial to the Participant as she enters middle school/adolescence. I understand that during the program, the Participant will be involved in outdoor physical activities. Physical reactions to exercise may include heat-related illness, abnormal heartbeats and blood pressure and, in rare instances, events such as heart attacks. While Girls on the Run takes all reasonable precautions, we can make no guarantees regarding these and other risks. Recognizing the risks of the program, and in consideration for allowing the Participant to participate in the program, I hereby release, discharge and agree to hold harmless, and to indemnify each of the Girls on the Run council conducting the Girls on the Run® program for Participant and Girls on the Run International, their owners, directors, affiliates, officers, contributors, sponsors, employees, contractors, agents and assigns against and from any and all causes of action, claims, demands, damages, costs, loss of services, expenses, compensation, consequential damages and attorneys’ fees (regardless whether pursuant to the laws of any county, state or country) claimed by, through or on behalf of me or the Participant related directly or indirectly to the program (including without limitation the 5k race), and specifically including any and all claims for personal injuries sustained while participating in program activities without regard to negligence or negligent conditions. In addition, I hereby authorize Girls on the Run, if after a reasonable attempt has been made to reach a parent, guardian or emergency contact to obtain consent, or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment, and hospital care, to be rendered to the Participant under the general or special supervision and on the advice of any physician or surgeon who may treat the Participant, and consent to any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment and hospital care, to be rendered to the Participant by any health care professional who may treat the Participant. I agree to pay for any such treatment and to reimburse Girls on the Run for all costs and expenses it may incur related to such treatment. I hereby grant Girls on the Run®, its National Title Sponsors, its National Sponsors, and all assigns, licensees, successors in interest, legal representatives, employees, consultants, and those acting with permission or authority of the aforementioned parties, the absolute, irrevocable and unrestricted right to use photographs, video likenesses and audio recordings (including without limitation all originals, negatives, prints and transparencies or any duplicates or reproductions of the foregoing) that have been or will be taken of the Participant (collectively, “Images”), in which the Participant may be included with others, to copyright the same, in the name of Girls on the Run or otherwise; to use, re-use, publish and republish the same in whole or in part, individually or in conjunction with other photographs and videos, and in conjunction with any printed matter, in any and all media now and hereafter known, and for any purpose whatsoever; and to use my name in connection herewith. I hereby release and agree to hold harmless Girls on the Run and all aforementioned entities, from any damages or liability relating to or arising from any use of or modification, alteration, distortion or other change to any of the Images and/or information gathered, unless it can be proven that such reproduction were maliciously caused, produced and published for the sole purpose of subjecting Participant to conspicuous ridicule, scandal, reproach, scorn and indignity. I hereby waive any claims I may have based on any usage of the Images, information gathered, or works derived thereof, including but not limited to claims for either invasion of privacy or libel. I represent, warrant and agree that the Participant will not disaffirm or disavow this release on the ground that the Participant was a minor on the date it is executed or any similar grounds whatsoever. I understand that my daughter may complete a confidential survey at the beginning and conclusion of the program. The survey assesses thoughts, feelings, and behaviors related to physical activity, self, and peers. This information will enable councils to determine whether improvements have occurred over the course of the season. No names will be included on the surveys; rather, a code number will be assigned to each girl that will only be known by council contacts. Registration and survey information is shared with Girls on the Run International. From time to time, Girls on the Run sponsors may provide products or offer services to participants. I understand that Participant may receive products or service offerings from sponsors of Girls on the Run, and consent to their provision and Participant’s receipt thereof. I expressly agree that this consent is intended to be as broad and inclusive a release of liability as permitted by applicable law and that if any provision thereof is held invalid, it is agreed that the remaining provisions shall, notwithstanding, continue in full legal force and effect. I hereby warrant and represent that I am 18 years old or older; I have carefully read this consent and agree to its terms and conditions, that before signing this agreement I had the chance to ask questions; and I am aware that by signing this consent, I assume all risks and waive and release certain substantial rights that I and Participant may have or possess against Girls on the Run council conducting the Girls on the Run® program for Participant and Girls on the Run International. To the extent permitted by applicable law, I hereby irrevocably and unconditionally waive trial by jury in any legal action or proceeding related to this agreement.

__________________________________

__________________________________

__________________

Guardian Name (please print)

Guardian Signature

Date

ATTENDANCE POLICY Participation is a twice a week commitment. Please do not register if your child cannot attend both days. The content of the program is more than just running, so attendance is very important to the integrity of the experience for ALL the participants (both the girl who is absent and the team who is missing her). If a participant is absent more than 4 lessons, Girls on the Run of WNC reserves the right to dismiss the participant from the program with no refund of program fees. Additionally, out of respect to our volunteer coaches' time, more than 3 late pickups (10 minutes or later) could result in dismissal from the program. I acknowledge that I have read and understand the Attendance Policy. __________________________________

__________________________________

__________________

Guardian Name (please print)

Guardian Signature

Date

GIRLS ON THE RUN PARENT/GUARDIAN ASSUMPTION OF RISK, COVENANT NOT TO SUE, AND RELEASE AND WAIVER OF LIABILITY FOR PROGRAM TRANSPORTATION, RELEASE, AND PICK-UP This is a legally binding ASSUMPTION OF RISK, COVENANT NOT TO SUE, AGREEMENT TO INDEMNIFY, AND RELEASE AND WAIVER OF LIABILITY FOR PROGRAM TRANSPORTATION, RELEASE, AND PICK-UP (“Agreement”) made by me in favor of each of the Girls on the Run councils conducting the Girls on the Run® (“GOTR”) program; and Girls on the Run International; and their owners, directors, affiliates, officers, contributors, sponsors, employees, contractors, agents, volunteers, and assigns. I am the parent or legal Guardian of _________________________________________________________, a minor (“Participant”). I agree that the Participant may participate in the GOTR program. I understand and acknowledge that the Participant’s participation in the GOTR program is voluntary. In consideration for GOTR allowing the Participant to participate in the GOTR program, I hereby covenant and agree as follows: I have read, understand, and agree with GOTR’s Pick-Up and Release Policy - Guardian Communication. Specifically, I agree that I am responsible for arranging/providing for the Participant’s transportation to and from all GOTR lessons and events in accordance with the terms of GOTR’s Pick-Up and Release Policy - Guardian Communication. On behalf of myself and my family, heirs, and personal representatives, I hereby accept and assume all risks (both foreseeable and unforeseeable and including, but not limited to, injury, damage to property, and death) arising out of or related to the release and pick-up of the Participant from GOTR lessons and events and the transportation of the Participant to and from GOTR lessons and events, including without limitation parking lot shuttles, and hereby assume all responsibility for all losses, costs, and/or damages related to such transportation even if caused, in whole or in part, by the negligence of GOTR or its employees or agents. Additionally, on behalf of myself and my family, heirs, and personal representatives, I hereby release, discharge, and covenant not to sue each of the Girls on the Run councils conducting the Girls on the Run® program; and Girls on the Run International; and their owners, directors, affiliates, officers, contributors, sponsors, employees, contractors, agents, volunteers, and assigns to the fullest extent permitted by law from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to the release and pickup of the Participant from GOTR lessons and events and the transportation of the Participant to and from GOTR lessons and events, including without limitation parking lot shuttles, even if caused, in whole or in part, by the negligence of GOTR or its employees or agents. This Agreement shall be construed in accordance with the laws of the state of North Carolina, which shall be the forum for any lawsuits filed in connection with or pursuant to this Agreement. The terms of this Agreement shall be severable such that if a court of competent jurisdiction holds any term to be illegal or unenforceable, the validity of the remaining portions of this Agreement shall not be affected thereby and shall still be enforceable to the extent permitted by applicable law. By entering into this Agreement, I am not relying on any oral or written representation or statements other than what is expressly set forth in this Agreement. I am fully competent to read and understand this Agreement, have carefully and thoroughly read it, fully understand its contents, and sign it of my own free will.

__________________________________

__________________________________

__________________

Guardian Name (please print)

Guardian Signature

Date

PICK-UP AND RELEASE POLICY – Guardian CommunicaCon Thank you for your interest in Girls on the Run / Heart & Sole! We are excited that your child is interested in par:cipa:ng in our program. Your child’s safety is very important to us and our Pick-Up and Release Policy is in place to ensure the well-being of every program par:cipant or youth volunteer age 15 and below. Please read the policy below to learn how we work together to keep your child safe. Please note that a signed Pick-Up and Release Policy - Agreement & Waiver is required for every program parCcipant or youth volunteer, which Parents and Guardians can complete during the registraCon process. AUTHORIZED PICK-UP & RELEASE PROCEDURES Guardians are responsible for arranging/providing transporta:on for their child(ren) to and from weekly lessons. During registra:on, you will be asked to iden:fy secondary guardians, emergency contacts and other people authorized to pick up your child. Children may only be released to guardians, emergency contacts, and authorized individuals listed on the child’s registra:on form and who are age 16 and up. If Authorized Individuals are driving a child, Guardians are responsible for ensuring the individual meets all legal driving requirements. Coaches and staff are required to contact 911 in cases where drivers may be impaired or under the influence.

For your child’s safety, a picture ID must be shown when picking up the child, un:l these individuals are known to your child’s coach. Please make everyone on your approved pick-up list aware of this policy so that they have an ID available. Contact Girls on the Run if you do not have a photo ID. Timely Pick-Up: Our coaches volunteer over 40 hours of their :me to lead the Girls on the Run / Heart & Sole teams. Please respect our coaches by picking up your child(ren) on :me. Pick-up is considered late if it occurs more than 10 minutes aEer the end of the session. The third instance of tardiness, involving the same child(ren), will result in your child(ren) being withdrawn from the program. No Show: If no one arrives to pick up your child within 10 minutes aEer the end of the session, the coach will call the Guardian(s) listed, then the Emergency Contacts, and lastly any Authorized Individuals whose phone numbers are provided un:l someone confirms they will pick up your child. As a last resort, if all persons listed are unreachable or unable to pick up your child, Girls on the Run will Girls on the Run will contact local authori:es to assist. Changes to Authorized Individuals: You may add or delete a person to the Authorized Individual list by sending a handwriGen note or electronic message (email or text) to the coach or Girls on the Run staff 24 hours in advance of the :me of pick-up. Make sure that recently added Authorized Individuals know to present their ID. Site Specific Pick-Up/Release Policies: If a program site has an exis:ng Pick-Up/Release Policy, Girls on the Run must follow the procedures set by the program site as well as those set forth here. Your coach will no:fy you if there are site-specific procedures to follow. Program TransportaCon/Private TransportaCon Companies: Guardians are responsible for arranging/providing transporta:on for their child(ren) to and from weekly lessons. Girls on the Run coaches, other volunteers and staff are not allowed to transport any child, outside of their immediate family. In addi:on, Girls on the Run will not release a child to private companies (e.g. Uber, LyE, Taxi Cabs, etc.) unless the driver’s name is listed as an Authorized Individual on the child’s registra:on form. AEer-School Programs and Coordinated TransportaCon SoluCons: If your Child par:cipates in an aEer-school program in addi:on to Girls on the Run or your family u:lizes an aEer-school ac:vity bus or a federal, state or local government funded transporta:on program that u:lizes private transporta:on companies, your Child will be released to whatever ac:vity or transporta:on that is designated on the Child’s par:cipant record. Guardians, Secondary/Emergency Contacts and Authorized Individuals will be contacted if at least 10 minutes have passed aEer the program ends and transporta:on has not arrived or the Child is unable to be delivered to the aEer-school program. Children Walking Home: Your child may walk home if you’ve iden:fied them as a “walker” on their program/volunteer registra:on form (electronic or paper version), and the child’s walking distance is 1 ½ miles or less. Children whose des:na:on is more than 1 ½ miles away must be released to a Guardian or Authorized Individual. You may change your child’s walking status by emailing the coach or Girls on the Run staff at least 24 hours before your child is to be released. For your child’s safety, the walker designa:on applies to weekly lessons only, and does not apply to the 5K or other special events. 5K/EVENT TRANSPORTATION Guardians must provide transporta:on to and from the Girls on the Run 5K or other special events. If your child needs transporta:on to aGend an event, please talk to your child’s coach or a Girls on the Run staff person in advance to discuss possible solu:ons that may be available. 5K/EVENT SUPERVISION AND LOST CHILD Guardians are responsible for the safety and whereabouts of their child(ren) at the Girls on the Run 5K or other special events and must provide supervision at all :mes. If you are unable to aGend the 5K or other special events and are unable to arrange supervision for your child, please talk to your child’s coach or a Girls on the Run staff person in advance of the 5K or special event. If you or your child(ren) cannot find one another at the 5K please go to the Lost Child Area. Girls on the Run may contact local authori:es to assist if an adult does not retrieve the child.