Select Week / Day Option1 WeekSingle DayTwo DaysThree DaysFour DaysHow Athletes to Register?(Required)Please enter a number from 1 to 4.General Family Information – Parent 1 or Legal Guardian 1Name(Required) First Last Cell Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent 2 / Guardian 2 Information (optional)Name First Last Cell PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact (mandatory - if either Parent cannot be reached)Emergency Contact(Required)Relationship(Required)Phone(Required)PhoneAthlete(s) InformationName(Required) First Last Gender(Required) Male Female Birth Date(Required) MM slash DD slash YYYY Cell PhoneGrade(Required)Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Email (provide only if you want athlete to receive email communications)Athlete #2 InformationName(Required) First Last Gender(Required) Male Female Birth Date(Required) MM slash DD slash YYYY Cell PhoneGrade(Required)Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Email (provide only if you want athlete to receive email communications)Athlete #3 InformationName(Required) First Last Gender(Required) Male Female Birth Date(Required) MM slash DD slash YYYY Cell PhoneGrade(Required)Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Email (provide only if you want athlete to receive email communications)Athlete #4 InformationName(Required) First Last Gender(Required) Male Female Birth Date(Required) MM slash DD slash YYYY Cell PhoneGrade(Required)Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Email (provide only if you want athlete to receive email communications)March Break Camp General Policies and Information The RFYL March Break Camp promotes an inclusive, safe and welcoming atmosphere where people are valued and respected. Please do not send your child to the March Break Camp with valuable items. Also, label all your child’s belongings to ensure its safe return. We cannot be responsible for any lost or stolen items. The camp will involve lots of physical activity so please bring two changes of clothes just in case your child needs a fresh outfit to wear. We at RFYL and the staff of our March Break Camp are advocates for healthy kids. Your child will be very active in several activities like playing games and sports so it’s important for them to bring a healthy nut-free lunch and snacks. We will provide water and snacks. Since the March Break will be facilitated indoors please provide your child with the appropriate clothing. If your child has a medical condition and needs medicine to be administered on site, please let us know so we can forward you our medication form. If your child becomes ill during the day we will contact, you to make a decision whether your child should be picked up or not. Upon registration, you will be provided with a calendar of daily activities your child will be participating in throughout the week. Client Health QuestionnaireMedical ConditionsPlease indicate any significant medical conditions, physical limitations, or any other concerns that might affect your child’ s/ward’s full participation in Gazelle training. Asthma Chronic Nosebleed Diabetes Digestive upsets Ear, Nose, Throat infections Dislocated shoulder; swollen, painful joints; ‘trick or lock’ knee or other joint disability Fainting Spells Feet or Leg problems Hemophilia/Bleeding disorders Heart problems Hernia History of Head Injuries Migraine Rash Recent illness or operation Rheumatic Fever Seizures Sleepwalking Urinary infections Other (specify) Please specify(Required)If condition selected, give details of usual treatment for each of the above conditions indicated:Please explain if your child/ward has any medical condition that requires any modification of his/her program.Allergies/AsthmaPlease list all known confirmed allergies to the following:FoodsIf foods are life-threatening, please explain the symptoms and the treatment:Medications:Other (e.g., bee or wasp stings, environmental allergies):Has your child/ward suffered any serious allergic or asthmatic reaction? Yes No If yes, please provide details, including the type and severity of reaction:Is allergy considered: N/A Mild Moderate Serious Life-Threatening Has a doctor prescribed an Epi-Pen for your child/ward?(Required) Ye No Has a doctor prescribed an inhaler for asthma? (Prescribed asthma inhalers must be carried by the child during training.)(Required) Yes No Has a doctor prescribed an inhaler for any other reason?(Required) Yes No Dietary RestrictionsPlease list any foods your child/ward should not eat for medical, dietary, or religious reasons:MedicationDoes your child/ward take prescribed medication on a regular basis? Please specify:What prescribed medication(s) should your child/ward have with him/her during training?GeneralDoes your child/ward wear or carry medical alert identification (e.g., bracelet)?(Required) Ye No If yes, please specify what is written on it:Does your child/ward have any other relevant medical condition that will require modification of the program?(Required) Yes No If yes, please explain:Should it become necessary for my child/ward to have medical care, I hereby give the coach permission to use her/his best judgment in obtaining the best of such service for my child/ward. I also understand that in the event of such illness or accident, I will be notified as soon as possibleWAIVERS, DISCLAIMERS & CONSENTPolicies I consent to the following Running For Your Life Policies: ! Registration Fees are non-refundable. ! For liability purposes, registration forms must be completed and Registration Fees must be paid prior to commencement of training.Medical(Required)Does Athlete have special needs; medical conditions or allergies you would like us to know about: Ye No Media Release(Required)I hereby give Running For Your Life consent to use and reproduce my child's name/image for promotional purposes related to Running For Your Life. My child’s first name (unless otherwise authorized)/image may be published or used in social media sites, newspapers, promotional videos, television commercials, program brochures, posters, on World Wide Web or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by Running For Your Life. I release Running For Your Life from any and all claims, of any nature, based on any uses of the above. Yes No Waiver Release and IndemnityI, the parent/guardian of the child named above give permission for such child to participate in the programs and services of Running For Your Life Inc., and consent to any necessary first aid or emergency medical treatment being given or provided for the child, waive any claims against the Running For Your Life Inc., the sponsors of said programs, or any of the Running For Your Life Inc. representatives, employees or volunteers, in respect to any personal injury to such child arising in any way at, from or in connection with the programs and services of Running For Your Life Inc. I am providing this waiver on behalf of such child and on behalf of my spouse and any other family members or other persons who might be entitled to assert such a claim as well as on my own behalf.(Required)I, the parent/guardian of the child named above give permission for such child to participate in the programs and services of Running For Your Life Inc., and consent to any necessary first aid or emergency medical treatment being given or provided for the child, waive any claims against the Running For Your Life Inc., the sponsors of said programs, or any of the Running For Your Life Inc. representatives, employees or volunteers, in respect to any personal injury to such child arising in any way at, from or in connection with the programs and services of Running For Your Life Inc. I am providing this waiver on behalf of such child and on behalf of my spouse and any other family members or other persons who might be entitled to assert such a claim as well as on my own behalf. Yes No IN CONSIDERATION of the acceptance of my registration and the permission to participate in the RFYL March Break Camp for the session for which I am registered, I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE Running For Your Life Inc. and all other associations, sanctioning bodies and sponsoring companies, and all other agents, officials, servants, contractors, representatives, successors and assigns OF AND FROM ANY AND ALL CLAIMS, demands, damages, costs, expenses, actions and causes of actions, where in law or equity, in respect of death, injury, loss or damage to my person or property, HOWEVER CAUSED arising or to arise by reason of my participation in said, whether as a spectator, participant, competitor or otherwise; whether prior to, during or subsequent to any such event and NOTHWITHSTANDING that some may have contributed to or occasioned by the negligence of any of the aforesaid. I FURTHER UNDERTAKE TO HOLD AND SAVE HARMLESS AND AGREE TO INDEMNIFY all of the aforesaid from and against any and all liability incurred by any or all of them arising as a result of, or in any way connected with my participation in the said event. By submitting this entry, I acknowledge having read, understood and agreed to the above waiver, release and indemnity. I warrant that I am physically fit to participate as a member of Running For Your Life Inc March Break Camp.(Required)IN CONSIDERATION of the acceptance of my registration and the permission to participate in the RFYL March Break Camp for the session for which I am registered, I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE Running For Your Life Inc. and all other associations, sanctioning bodies and sponsoring companies, and all other agents, officials, servants, contractors, representatives, successors and assigns OF AND FROM ANY AND ALL CLAIMS, demands, damages, costs, expenses, actions and causes of actions, where in law or equity, in respect of death, injury, loss or damage to my person or property, HOWEVER CAUSED arising or to arise by reason of my participation in said, whether as a spectator, participant, competitor or otherwise; whether prior to, during or subsequent to any such event and NOTHWITHSTANDING that some may have contributed to or occasioned by the negligence of any of the aforesaid. I FURTHER UNDERTAKE TO HOLD AND SAVE HARMLESS AND AGREE TO INDEMNIFY all of the aforesaid from and against any and all liability incurred by any or all of them arising as a result of, or in any way connected with my participation in the said event. By submitting this entry, I acknowledge having read, understood and agreed to the above waiver, release and indemnity. I warrant that I am physically fit to participate as a member of Running For Your Life Inc March Break Camp. Yes No I am the parent and/or legal guardian of the child being filmed and understand the foregoing statements of Waiver and Media Releases, and am competent to execute this agreement.(Required)I am the parent and/or legal guardian of the child being filmed and understand the foregoing statements of Waiver and Media Releases, and am competent to execute this agreement. Yes No Additional Information / CommentsTotal If experiencing PayPal issues for payment please EMT fees to [email protected]
