The Speed Team RVA Registration Form
Athlete Name
*
First Name
Last Name
Athlete Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
Non-binary
Race (check all that apply)
*
American Indian
Asian
Black
White
Hawaiian/ Pacific Islander
Hispanic/ Latino
*
Yes
No
Athlete Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Athlete Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Athlete Email
*
example@example.com
School Attending SY 26-27
*
Grade SY 26-27
*
Athlete Event Interest
Sprints
Long Sprints
Jumps
Throws
Hurdles
Briefly list or describe any current or previous track & field or performance training experience:
*
Parent/ Guardian Information
Parent 1 Contact Name
*
First Name
Last Name
Relationship to Athlete
*
Mother
Father
Guardian
Other
Parent 1 Contact Phone
*
Format: (000) 000-0000.
Parent 1 Contact E-mail
*
example@example.com
Parent 1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Household Income
*
Under 25,000
25,000 - 49,999
50,000 - 74,999
75,000 - 99,999
100,000 or more
Parent 2 Contact Name
First Name
Last Name
Relationship to Athlete
Mother
Father
Guardian
Other
Parent 2 Contact Phone
Format: (000) 000-0000.
Parent 2 Contact E-mail
example@example.com
Parent 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Comments / Questions:
Back
Next
Save
Consent to Disclose Student Records for Record Sharing
This program, The Speed Team RVA is funded by the City of Richmond’s Positive Youth Development and Youth Violence Program. The goal of the City of Richmond’s Positive Youth Development and Youth Violence Program is to promote positive youth development and prevent youth violence and help your child reach his or her full potential—socially, emotionally, and academically. To help the City of Richmond achieve that goal, we may need to share certain information about your child with the City of Richmond and NextUp RVA. The City of Richmond has contracted NextUp RVA to distribute funds, provide technical assistance and evaluate programs’ impact on youth outcomes. In turn, they may need to share certain information about your child with us. NextUp RVA is committed to ensuring all youth have a positive, quality learning experience, and sharing this information can help us better serve your child(ren). Additionally, this information will help us understand whether or not this program is having a positive impact on your child’s academic, social, and emotional well-being.Also, to improve the program and make sure it meets the needs of youth, schools, and the community, we may conduct surveys to ask questions about the kinds of programs students would like to see, what they are learning from their participation in the programs and how they view themselves as learners and how they relate to their peers and adult staff. The answers to the surveys will be used to evaluate and improve the City of Richmond’s Positive Youth Development and Youth Violence Program. Richmond Public Schools (RPS) requires your consent to disclose data regarding your child in accordance with the Family Educational Rights and Privacy Act (FERPA), which protects the privacy of student educational records to NextUp.
By signing this form, you are granting permission for RPS to disclose educational data related to your child as permitted under FERPA to NextUp, ensuring the confidentiality and security of their academic records.
*
Yes, I give my permission to allow RPS to disclose my child’s school records to NextUp RVA.
No, I do not give my permission to allow RPS to disclose my child’s school records to NextUp RVA.
Participant Name
*
First Name
Last Name
Signature
*
Parent/ Guardian Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
Save
Media ReleaseMedia Release Waiver
Thank you for allowing your child to participate in The Speed Team RVA programming. We occasionally take photographs, videos, and/or written or recorded testimonials to highlight the impact of our programs and partnerships. With your permission, these materials may be used in marketing and/or promotional material for The Speed Team RVA and/or funding partner NextUp RVA.
I, the undersigned, hereby grant The Speed Team RVA and NextUp, its partners, and authorized representatives permission to: Photograph, videotape, or record my child’s voice or written statements; Use these images, videos, or testimonials in promotional, educational, or fundraising materials, including but not limited to: websites, social media, newsletters, printed publications, grant reports, or presentations; Share these materials with partner organizations or media outlets to help promote NextUp's mission. I understand that: My child’s full name will not be used without additional written permission. I will not receive compensation for the use of these materials. This release is voluntary and will remain in effect until I revoke it in writing.
*
Yes, I give permission for The Speed Team RVA and NextUp to photograph, record, and use media of my child as described above.
No, I do not give permission
Participant Name
*
First Name
Last Name
Signature
*
Parent/ Guardian Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
Save
Release of Liability Agreement
In consideration of being allowed to participate in training with The Speed Team RVA Performance, I, on behalf of myself, my heirs, executors, administrators, assigns, and representatives, hereby release, discharge, and hold harmless The Speed Team RVA Performance, its owners, trainers, coaches, employees, volunteers, and agents from any and all liability, claims,demands, or causes of action related to any injuries, damages, or losses resulting from participation, whether caused by negligence or otherwise.
Acknowledgements and Understanding
1. I am voluntarily participating with knowledge of the risks involved. 2. I am physically capable and have no medical conditions that would impair my ability to safely participate. 3. Training sessions may take place at multiple locations in Richmond, VA, including outdoor venues, and The Speed TeamRVA Performance is not responsible for hazards or unsafe conditions related to the venue.
Participant Name
*
First Name
Last Name
Signature
*
Parent/ Guardian Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Back
Next
Save
Medical & Emergency Contact Information
CONFIDENTIAL PROGRAM RECORD — Provide information reasonably necessary for safe participation and emergency response.
Athlete Information
Athlete Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Information
Emergency Contact #1
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical & Insurance Information
Primary Physician/Pediatrician
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health Insurance Provider
Policy/ Member ID
Please identify any applicable conditions or concerns:
Asthma / exercise-induced breathing condition
Allergies
Severe allergic reaction / anaphylaxis
Seizure history
Diabetes / blood-sugar management concern
Heat-related illness history
Physician-imposed activity restriction
Currently under medical care for an athletic injury
Other information relevant to safe participation
No Known Allergies or Conditions
Please explain all items selected above:
Medications relevant to athletic participation or emergency care ( If none, please type N/A):
*
Identify any current or recent injuries, rehabilitation, restrictions, or return-to-play/return-to-training instructions that coaches should know:
Has a physician or medical professional restricted the athlete's participation?
*
Yes
No
If Yes, please explain:
Emergency Medical Authorization
If the Participant becomes injured or ill and the Parent/Guardian cannot reasonably be contacted, I authorize Speed Team RVA coaches, staff, contractors, volunteers, or representatives to obtain or facilitate reasonably necessary emergency assistance. This may include first aid, CPR/AED response, activation of emergency medical services, ambulance transportation, emergency room evaluation, and other emergency medical care considered reasonably necessary by qualified medical personnel. I understand that Speed Team RVA does not guarantee that medical personnel will be present at every training session. I authorize qualified emergency medical personnel to provide care consistent with their professional judgment. Except where otherwise required by law or insurance coverage, the Participant/Parent/Guardian remains responsible for costs associated with medical evaluation, transportation, and treatment.
Health Information Accuracy & Updates
I certify that the information provided on this form is accurate to the best of my knowledge. It is the responsibility of the Participant and Parent/Guardian to notify Speed Team RVA if relevant medical information, restrictions, medications, injuries, or emergency contact information changes during the program year. Providing this information does not make Speed Team RVA responsible for diagnosing, treating, or managing a medical condition.
Acknowledgement & Agreements
Athlete Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PARENT / LEGAL GUARDIAN CONSENT
Required for participants under 18. I certify that I am the participant's parent/legal guardian or otherwise have legal authority to provide this consent.
Parent Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print Form
Save
Submit Form
Submit Form
Should be Empty: