Robert J Kane Invite 400m Champion

Client Health Questionnaire

All information received on this form will be treated as strictly confidential. Please fill out completely and accurately. This information is
essential to helping us develop a program that addresses your child’s goals and interests and is safe and effective.

AsthmaFainting SpellsHistory of Head InjuriesRheumatic FeverChronic NosebleedFeet or Leg problemsMigraine SeizuresDiabetesHemophilia/Bleeding disordersRash SleepwalkingDigestive upsetsHeart problemsRecent illness or operationUrinary infectionsEar, Nose, Throat infectionsHerniaDislocated shoulder; swollen, painful joints; ‘trick or lock’ knee or other joint disability
Other(Please Specify):

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/Asthma

Please list all known confirmed allergies to the following:

(a) Foods:

If foods are life-threatening, please explain the symptoms and the treatment:

(b) Medications:

(c) Other (e.g., bee or wasp stings, environmental allergies):

Has your child/ward suffered any serious allergic or asthmatic reaction?YesNo

If yes, please provide details, including the type and severity of reaction:

Is allergy considered: MildModerateSeriousLife-Threatening

Has a doctor prescribed an Epi-Pen for your child/ward? YesNo

Has a doctor prescribed an inhaler for asthma? (Prescribed asthma inhalers must be carried by the child during training.) YesNo

Has a doctor prescribed an inhaler for any other reason? YesNo

Dietary Restrictions

Please list any foods your child/ward should not eat for medical, dietary, or religious reasons:

Medications

Does 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?

General

(1) Does your child/ward wear or carry medical alert identification (e.g., bracelet)? YesNo

If yes, please specify what is written on it:

(2) Does your child/ward have any other relevant medical condition that will require modification of the program? YesNo

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 possible.

Waiver Release and Indemnity

IN CONSIDERATION of the acceptance of my application and the permission to participate as an entrant of membership, practice, competition, or any other event as part of The Gazelles XC Club and Running For Your Life Inc., during the season for which I am registered, I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE The

Gazelles XC Club, Running For Your Life Inc., Athletics Ontario, Minor Track Association (MTA) 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 The Gazelles Track and Field Club.

Release Form for Media Recording

I, the undersigned, do hereby consent and agree that Running for Your Life, its employees, or agents have the right to take photographs, videotape, or digital recordings of me while training with Running for Your Life and to use these in any and all media, now or hereafter known, and exclusively for the purpose of a video and/or picture displaying activities, training, coaching, mentoring and testimonials. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

I do hereby release to Running for Your Life Inc., its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.

I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.

I also understand that Running for Your Life Inc., is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

POWER OF ATTORNEY for use in 2018/2019:

(The Power of Attorney is used to allow you, the Donor (either athlete or parent/guardian of athlete), to appoint a representative to be your attorney and to sign Athletics Ontario & Minor Track Association entry forms, waivers etc. on your behalf)

I appoint all or any Staff and/or Gazelle Coach of Running For Your Life Sports Performance Group / The Gazelles, jointly and severally, to be my attorney(s) in accordance with the Powers of Attorney Act and to do on my behalf anything that I can lawfully do by an Attorney.

This power of attorney is subject to the following conditions and restrictions: This Power of Attorney shall only apply to enable my said attorney(s) to execute such entry forms, waivers and other documents as may be required to permit me or the Athlete named above to participate in any event sponsored or sanctioned by Athletics Ontario & Minor Track Association during the /2018 calendar years commencing January 1st 2018 ending on August 31st, 2018.

I hereby acknowledge that by signing such entry forms, waivers and other documents that my attorney(s) may WAIVE ANY AND ALL CLAIMS that I, the Athlete Named Above, my heirs, executors, administrators, successors and assigns may have against The Gazelles XC Club, Running For Your Life Inc., Athletics Ontario & Minor Track Association and its respective agents, officials, employees, contractors, representatives, successors and assigns with regard to ANY demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect of death, injury, loss or damage to my person or property HOWSOEVER CAUSED arising or to arise by reason of my participation or the participation of the Athlete Named Above in any Gazelles Track & Field, Running For Your Life Inc., Athletics Ontario & Minor Track Association sponsored or sanctioned event in the said 2018 calendar year, whether prior to, during or subsequent to any such event and NOTWITHSTANDING that same may have been contributed to or occasioned by the NEGLIGENCE of any of the aforesaid.

I represent that I am at least 18 years of age, have read and understand the foregoing statements of Waiver, Media Releases and Power of Attorney above and am competent to execute this agreement.I am the parent and/or legal guardian of the child being filmed and understand the foregoing statements of Waiver, Media Releases and Power of Attorney above, and am competent to execute this agreement