Indian Lake Elementary Running Club Pick-Up and Information Form If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Student's Full Name: (First M.I. Last) * T-Shirt Size: * Youth Small Youth Medium Youth Large Youth Extra Large Grade: * K 1 2 3 4 5 2nd Student's Full Name (Leave N/A if not applicable) T-Shirt Size 2: (N/A if not applicable) N/A Youth Small Youth Medium Youth Large Youth Extra Large Grade 2: (N/A if not applicable) N/A K 1 2 3 4 5 3rd Student's Full Name (Leave N/A if not applicable) T-Shirt Size 3: (N/A if not applicable) N/A Youth Small Youth Medium Youth Large Youth Extra Large Grade 3: (N/A if not applicable) N/A K 1 2 3 4 5 4th Student's Full Name (Leave N/A if not applicable) T-Shirt Size 4: (N/A if not applicable) N/A Youth Small Youth Medium Youth Large Youth Extra Large Grade 4: (N/A if not applicable) N/A K 1 2 3 4 5 Parent/Guardian: Mother's Name: (First Last) * Father's Name: (First Last) * Address: (Street City State Zip) * Mother Home Phone: (Insert N/A if not applicable) * Mother Mobile Phone: (Insert N/A if not applicable) * Father Home Phone: (Insert N/A if not applicable) * Father Mobile Phone: (Insert N/A if not applicable) * Emergency Contact: (First Last / Relationship) * Emergency Contact Phone: * Parent/Guardian Email: * Allergies? (If yes please list): * Other Health Concerns? (If yes please list): * John Doe / Father / 555-555-5555 * It is hereby acknowledged that running can be potentially dangerous and I assume all risks on behalf of my child. By consenting for my child to participate in the Indian Lake Elementary After School Running Club, I hereby release for myself and on behalf of my child, Indian Lake Elementary, the Sumner County Board of Education and Sumner County, Tennessee and anyone or other organization involved in the Indian Lake Elementary After School Running Club or the event, their employees, agents or representatives, from any and all claims of liabilities of any kind whatsoever arising out of my child’s voluntary participation in the Indian Lake Elementary After School Running Club. By checking the box below, I/we hereby consent for my child/children to participate in the School Running Program at Indian Lake Elementary as they practice and/or prepare for the upcoming Music City Marathon for Kids. This acknowledgement of risk and consent to allow participation shall remain in effect until revoked in writing. Yes, I agree. * My child is adequately and currently covered by accident insurance that will cover injuries sustained while participating in the Indian Lake Elementary Running Program. Insurance Information Please complete the information below to verify insurance coverage for your child for the 2016 – 2017 school year. Insurance Company Name: * Initial here: * Person Insured: * Policy Number: * I can volunteer for practice: (Wednesdays 7:45-8:10) * No Yes I can volunteer for the marathon: (Sunday, April 28th) * No Yes
