Join the Club: Kids Run Club Application & Participation WaiverGive your 9-12 year old permission to participate, and join the club! Participant's Name * First Name Last Name Birthdate * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country School and Grade * List the most recent school and grade attended. Legal Guardian's Name(s) * First Name Last Name Relationship to Child * Email * Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Does your child have previous experience with running? It is not required to have experience to join, but good to know. * Yes No Describe any previous experience with cardio activities (team sports, swim team, etc) * Describe your child's current level of fitness and any exercise activities they currently participate in. * Is your child healthy enough to participate in physical activities that will challenge their current level of fitness? Yes No Describe any injury or medical related issues that your child has or has had. * Does your child have any allergies? If so, please list which allergies. * Is there anything you'd like me to know about your child's emotional or physical health history? * What do you hope your child gets out of participating in this group? * Check your consent to the following clauses: * Your child will be encouraged to engage in cardio exercise 3 or more times per week for 10-30 minutes at a time during the course of this session. Kjersti will provide specific training adjustment for every child's unique starting place as needed. It is essential that parents are supportive in helping their child establish a movement routine. Training recommendations will be included in the original booklet received by the first day. Your child will need appropriate footwear (running shoes), comfortable clothes, and possibly a sports bra. You agree that you will see that your child is appropriately dressed for movement activities including running, yoga, and play. Each child is to be sent with a water bottle to each meetup, and wearing sunscreen. Some meetups may have snacks, like fresh fruit, provided. Check if you consent that your child can partake. Leave blank if you don't consent. Your child may be photographed during meetups. Check if you consent that these pictures may be shared with the group, or for marketing materials. You agree to pay the fee for the session regardless whether your child attends each meetup. How did you hear about Kids Run Club? A friend A Flyer Google Other Is there anything else you'd like me to know? I consent to the participation of my child, (who's name is stated in the above form) in all of the activities, programs and services offered by Kjersti Nelson, MFT, Long Distance Running Coach, & RYT 200. I understand that each participant has a different capacity for participating in such activities, programs and services. I am aware that all activities, services, and programs offered are educational, recreational, or self-directed in nature. I assume full responsibility during and after my child's participation in any and all classes, groups, clubs, and or therapy. Any portion of the information or instruction I, or my child, receive is assumed the participant's and their parents (or legal guardian) responsibility. I understand the risk involved in any activity or program is relative to participants state of fitness or health (physical, mental or emotional) and the awareness, care and skill with which the participant conducts their behavior in that activity or program. I acknowledge that mine and my child's choice to participate in any activity, service and program of Kjersti Nelson, MFT, Long Distance Running Coach & RYT 200 brings with it the assumption by me and my child those risks or results stemming from these choice(s) and the fitness, health, awareness, care and skill that I/they possess and use. In addition, I understand that I or my child are free to withdraw from, reduce, or modify mine/their involvement in any program activity. I realize that I/ they should do so upon recognition of any signs of transient lightheadedness, fainting, chest discomfort, leg cramps, nausea, injury, etc. I understand that running, walking, and yoga are potentially hazardous activities. I agree to disallow my child to participate in running/walking/yoga unless they are medically able. I assume all risks associated with running, walking, and yoga which could include, but is not limited to: falls, the condition of the course and road, traffic, contact with other participants, and the effects of weather including heat, humidity, cold and rain, on behalf of myself and/or child. Al such risks are known and understood by me. I, the undersigned, hereby waive and release Kjersti Nelson MFT, Long Distance Running Coach & RYT 200, and anyone acting on her behalf, from any and all claims and liabilities of any kind arising out of my child's participation in this course/club/experience. In consideration of being allowed to participate in any way in the course/club/experience, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that: The risk of injury from the activities involved in this program is significant, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury or death does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of others, and assume full responsibility for my or my child's participation. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my or my child's presence or participation, I/they will remove my/themself from participation and bring such to the attention of the Kjersti Nelson (Coach) immediately. For myself, child, and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless Kjersti Nelson LMFT Running + Therapy, Long Distance Running Coach, RYT 200. * I consent and give permission I do not consent or give permission I declare that I have read, understand, and agree to the contents of this informed consent waiver for running, walking, yoga, and physical activity agreement in it's entirety. * Type your full name and date to accept. Thank you!
