WE Run Registration Form
Thank you for your interest in signing your child(ren) up for WE Run! Please complete all questions below. Thank you!
Child Information:
Name
*
First Name
Last Name
Child's School
*
Cherokee Elementary
Endeavor Elementary
VanGorden Elementary
Woodland Elementary
Child's Grade
*
3rd
4th
5th
6th
Child's Age
*
Child's T-shirt Size
*
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Youth or Adult Shoe Size
*
Youth
Adult
Child's Shoe Size
*
If there are allergies/medical conditions that may affect any food that is offered or activity that is performed, please list below:
If there are any behavioral or emotional behaviors that I should be made aware of to ensure your child has a safe and enjoyable experience, please list below:
Child Information:
Please complete this if registering more than one child.
Name
First Name
Last Name
Child's School
Cherokee Elementary
Endeavor Elementary
VanGorden Elementary
Woodland Elementary
Child's Grade
3rd
4th
5th
6th
Child's Age
Child's T-shirt Size
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Youth or Adult Shoe Size
Youth
Adult
Child's Shoe Size
If there are allergies/medical conditions that may affect any food that is offered or activity that is performed, please list below:
If there are any behavioral or emotional behaviors that I should be made aware of to ensure your child has a safe and enjoyable experience, please list below:
Guardian Information:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
This email will be the primary contact and be included on the email listing for program communications.
Emergency Contact/Second Guardian Information:
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
I would like this email included in the email listing for program updates.
*
Yes
No
Media Release
During WE Run, we take photographs of activities involving the participants to share with you all. Some photographs may capture your child's participation, directly or indirectly. These photos may also be published through our website and social media pages. Therefore, we seek your consent in allowing us to publish photos which may involve your child(ren) to the said platforms. Please select your choice below.
*
I hereby allow the reproduction and publication of my child(ren)'s photograph(s).
I do not allow the reproduction and publication of my child(ren)'s photograph(s).
Pick-up Option
My child(ren) will:
*
Walk/ride their bike home from WE Run
Will be picked up
Besides myself, others authorized to pick up my child(ren) include (if not applicable, put N/A):
*
Late Pick-up Policy
WE Run ends at 4:30 pm. Parents/Guardians are asked to plan sufficient time to be at dismissal by 4:30. If the parent/guardian is aware that they are going to be late, they should call/text Lamia at 317-286-8027 to advise her of this and of their plan to pick up their child/ren. They should also understand that a late fee will be charged. From 4:40 pm onward there will be a per-child late fee of $10 and an additional $1 per minute for anything after 4:45 pm.
I understand the above Late Pick-up Policy and agree to its terms by signing below.
*
Date
*
-
Month
-
Day
Year
Date
Behavior Management Policy
In order to foster a positive, respectful, safe, and productive program environment by encouraging good behavior and addressing inappropriate actions in a structured and fair manner, WE Run has implemented a behavior management policy based on a "three strikes" system. The aim is to give students the opportunity to correct their actions before more serious consequences are applied, while maintaining consistency and fairness, as well as a safe and enjoyable environment for all. Students are expected to: 1) Be respectful of the WE Run coaches, their fellow WE Run participants, and school property; 2) Follow program rules and instructions; 3) Actively participate in the activities. Strike 1 will be a verbal warning; Strike 2 will result in parent/guardian contact; Strike 3 may lead to removal from the program.
I understand the above Behavior Management Policy and agree to its terms by signing below.
*
Date
*
-
Month
-
Day
Year
Date
Liability Waiver and Release Form
This is a release of legal rights. Read and understand before signing.
I hereby certify that I am the adult parent or guardian of the above minor child(ren) under the age of eighteen years, and I consent to their participation in recreational activities during the WE Run program (the “Program”) located at my child(ren)'s elementary school, acting by and through Amex Health, LLC and their use of equipment supplied by Amex Health, LLC. I understand and acknowledge that I am fully aware of and assume the risks (including but not limited to the risk of serious bodily injury, property loss or damage) of (1) said minor child(ren)’s participation in recreational activities at the Program and (2) their use of the equipment. I recognize my responsibility to ensure that said minor child(ren) participates only in those activities for which they have the required skills, qualifications, training and physical conditioning. I understand that Amex Health, LLC and their employees shall have no responsibility to pay for medical treatment and related costs if said minor child(ren) is/are injured. I further understand and agree that Amex Health, LLC supplies the equipment “as is”, and that Amex Health, LLC disclaims all warranties, express or implied, including warranties of merchantability and fitness for a particular purpose. Knowing the risks described above, I agree, personally and on behalf of the minor child(ren) named above, to assume all the risks and responsibilities surrounding my minor child(ren)’s participation of the Program and use of the equipment. To the fullest extent allowed by law, I hold harmless and agree to indemnify Amex Health, LLC, its officers, directors, faculty, staff, volunteers, employees and agents, from and against any present or future claim, cause of action, loss or liability for injury to person or property, which said minor child(ren) may suffer or for which said minor child(ren) may be liable to any other person, related to said minor child(ren)’s participation in recreational activities at the Program and use of the equipment, resulting from any cause whatsoever, and regardless of fault. I am at least eighteen years of age and have carefully read and freely signed this Liability Waiver and Release Form. I understand and agree that no oral or written representations can or will alter the contents of this document. HAVING READ THE ABOVE TERMS AND INTENDING TO BE LEGALLY BOUND HERBY UNDERSTANDING THIS DOCUMENT TO BE A COMPLETE WAIVER AND DISCLAMER IN FAVOR OF AMEX HEALTH, LLC, I HEREBY AFFIX MY SIGNATURE HERETO.
*
Date
*
-
Month
-
Day
Year
Date
Consent to Treat a Minor
This form grants temporary authority to Amex Health to provide and arrange for medical or surgical treatment for a minor in the event of an emergency or when the minor is not accompanied by either parents or legal guardians. This form is to be utilized when the parent or legal guardian is unavailable. Authorization and Consent of Parent(s) or Legal Guardian(s): I, as parent/legal guardian, do hereby state that I have legal custody of the Minor(s) listed below and the authority to authorize Amex Health to consent on my behalf. I grant my authorization and consent for Amex Health to administer general first aid treatment for any minor injuries or illnesses experienced by the below referenced Minor(s). If the injury or illness is life threatening or requires emergency treatment, I authorize Amex Health to summon any and all professional emergency personnel to attend, transport, and treat the minor(s) and to issue consent for any laboratory, radiological or other diagnostic procedures, anesthesia, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of and as deemed necessary by, any licensed physician, surgeon, dentist, hospital, or other healthcare providers or institution duly licensed to practice in the state in which such treatment is to occur. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the Amex Health in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. This form is valid for the length of the activity program or unless revoked in writing.
Child's Name
*
First Name
Last Name
Child's Medications or Chronic Disease Information
*
Child's Name (if applicable)
First Name
Last Name
Child's Medications or Chronic Disease Information (if applicable)
Child's Physician
*
Phone Number
*
-
Area Code
Phone Number
Insurance Name
*
Insurance Policy Number
*
Preferred Hospital
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Payment Information
All payments for WE Run are due by the Friday of the first week of the program. Payments received after this date will be charged a $10 late fee.
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WE Run Registration
$130 per child
$
130.00
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