Monroe County Community School Corporation®

Running Club – Binford Elementary School

WAIVER, RELEASE OF LIABILITY AND CONSENT TO MEDICAL ATTENTION

In consideration of my being allowed to use any Monroe County Community School Corporation Fitness Facility (the “Facility”) and participate in any Fitness Program (the “Program”), I for myself and each family member under the age of 18 agree and acknowledge as follows:

Voluntary Participation

·  I understand and confirm that my use of the Facility and participation in the Program is voluntary and is not a requirement of Monroe County Community School Corporation or any of its affiliates.

Identification of Risks

·  I understand that my use of the Facility and participation in the Program involves risk of injury, disability, damage to property and death. I also understand that the Facility and Program are unsupervised.

Assumption of Risk

·  I am physically able to use the Facility and participate in the Program and assume all risks, known or unknown, connected with my use of the Facility or Program participation. I will not use any equipment with which I am not completely familiar without first being instructed on the proper use of such equipment by Facility personnel. I accept personal responsibility for any liability, injury, loss or damage in any way connected with my use of the Facility or Program participation.

Waiver and Release

·  I release and discharge Monroe County Community School Corporation and each of its officers, directors, employees, agents, successors and assigns from all claims for any liability, injury, loss, damage or death in any way connected with my use of the Facility or participation in the Program, whether caused in whole or in part by the negligence of any of the organizations or individuals referred to above. I intend for this waiver and release also to apply to my relatives, personal representatives, heirs, beneficiaries, next of kin or assigns who might pursue any legal action for claim for such liability, injury, loss, damage or death.

Consent to Medical Treatment

·  I agree that Monroe County Community School Corporation may, but has no duty to, provide me, through medical personnel of its choice, medical assistance, transportation and emergency medical services. This consent does not impose a duty upon Monroe County Community School Corporation to provide any such assistance, transportation or services.

I have read this waiver, release, and consent and understand that I have given up substantial rights by signing it. I am signing this waiver, release, and consent voluntarily. Please sign on other side.

Permission to Participate in Binford Elementary School

After-School Running Club

Grades 5 and 6

I give permission for my child, ______, to participate in the Binford Elementary School after-school running club. The purpose of the running club is to enhance the physical fitness of students, and build running stamina.

Students will run with adult supervisors through neighborhoods surrounding Binford; in event of driving rain, students will practice indoors. Please make sure they have some warm clothes to run outside in.

Students will work toward the goal of running a 5K, which will be optional and not during school hours. The 5K that I am getting the students ready for is on April 8th at the Hoosier Half and 5K.

www.hoosierhalf.com

I understand that my child will report to the gym at 3:50pm. The running club will meet until 5:00 p.m. at which time I am arranging for my child to go to extended day, be picked up or walk home. The club will meet on Tuesdays and Thursdays beginning February 7th to April 6th.

Please check one of the following transportation options:

□ I will arrange for my child’s transportation home at the end of the program.

□ My child has permission to walk home from the program.

□ My child is enrolled in Extended Day and should go there.

Exceptions to these arrangements must be in writing, signed by parent/guardian.

I understand that this is a voluntary program and there is no fee for participation. I further understand that my child may be dismissed from the program for inappropriate behavior.

Any questions regarding the program can be directed to Mr. Shepherd at 330-7741 ext. 50657 or via email. Deadline for returning permission slips is the end of the school day on Feb. 6th.

During the time this program is in operation, I may be reached at (phone) ______.

In the event I cannot be reached, another emergency contact is: ______

Emergency Contact Phone Number ______.

Child’s Name Child’s Teacher

______

Parent’s Signature Parent’s Name Printed

Address/Email

______