Speeder Kids Running Club Waiver

Please fill out the Waiver and Release of Liability for each child that is participating in the Speeder Kids Running Club.

Student's first name

Child's last name

Grade

Teacher

Date of Birth

Month

Day

Year

Age

Parent/Guardian name

Primary Phone

Secondary Phone

Emergency Contact Information

Name

Relationship to Student

Phone

Alternate Emergency Contact

Name

Relationship to Student

Phone

Health Information

Please answer each question completely. If you answer Yes, provide additional information so our coaches and school personnel can respond appropriately if needed.

General Health

Does your child have any medical condition that may affect their ability to participate in running or physical activity?

Yes

If yes, please explain:

Has your child ever been advised by a healthcare provider to limit or avoid physical activity or exercise?

Yes

If yes, please describe any restrictions:

Allergies

Does your child have any allergies?

Yes

If yes, please list the allergy and describe the reaction:

Does your child require an EpiPen or other emergency medication?

Yes

If yes, please describe:

Please ensure any required emergency medication is available according to school/program policy.

Asthma or Breathing Conditions

Does your child have asthma or another breathing condition?

Yes

If yes:

Does exercise trigger symptoms?

Yes

Does your child use an inhaler or other medication?

Yes

Where will the medication be kept during the program?

Are there specific symptoms or warning signs coaches should know?

Seizures

Has your child ever experienced a seizure or been diagnosed with a seizure disorder?

Yes

If yes, please provide any information that would be important for coaches to know:

What does a typical seizure look like for your child?

Are there specific signs or symptoms that may occur before a seizure?

What should coaches do if your child experiences a seizure?

Is there emergency medication or a specific emergency procedure that may be required?

Yes

If yes, please explain:

Where will any required medication be kept during the program?

Does your child have a seizure action plan on file with the school?

Yes

Not applicable

Is there anything else our coaches should know about your child's seizure history or safety needs?

Heart or Exercise-Related Symptoms

Has your child ever experienced any of the following during exercise or physical activity?

Chest pain, pressure, or discomfort:

Yes

Unexplained fainting or passing out:

Yes

Unexplained dizziness:

Yes

Unusual shortness of breath or difficulty breathing:

Yes

Racing, pounding, or irregular heartbeat:

Yes

If yes to any of the above, please explain:

Has your child ever been advised by a healthcare provider not to participate in sports or strenuous exercise because of a heart or circulation condition?

Yes

If yes, please explain:

Injuries & Physical Conditions

Does your child currently have an injury, pain, or physical condition that may affect running, jumping, or other activities?

Yes

If yes, please explain:

Permission to Use Photograph

I grant to Schock Fitness & the Speeder Kids Running Program, its representatives and employees the right to take photographs of me, my child/ children and my property. I authorize Schock Fitness & the Speeder Kids Running Program, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Schock Fitness & the Speeder Kids Running Program may use such photographs of me, my child/ children and property for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

Photography Permission

I give Schock Fitness permission to use photographs as stated above.

I do not give Schock Fitness permission to use photographs as stated above.

Expectations for Participation:

To ensure the safety and enjoyment of all participants, each child must:

Listen and follow coach directions throughout each session.
Wear sneakers to each session.
Bring a water bottle with their name on it. The water bottle must be filled prior to each session.
Wear appropriate clothing for weather conditions, including sunscreen and a hat if needed.
Use the bathroom before arriving at the session.

Program Rules:

Have fun!
Keep hands to yourself—no touching others.
No gymnastics or martial arts (e.g., cartwheels, flips, kicks, punches, etc.).
If a break is needed, use the designated break area for a maximum of 2 minutes.
When a coach raises their hand, all children must be quiet and listen for instructions. If a child is proving to be continuously disruptive during a SKRC session, the coaches will inform the parents.

Acknowledgment of Risk & Release of Liability:

I, the undersigned parent/guardian, acknowledge that participation in the Speeder Kids Running Club involves physical activity and the risk of injury, including but not limited to falls, contact with other participants, and environmental hazards. I voluntarily assume all risks associated with my child’s participation in this program.

I hereby release and hold harmless Schock Fitness & Pilates, its coaches, employees, volunteers, and affiliated organizations from any claims, liabilities, or damages arising from my child’s participation in the Speeder Kids Running Club. I certify that my child is in good health and has no medical conditions that would prevent them from safely participating in physical activities.

If my child requires additional support services to participate in the Speeder Kids Running Club, I understand that it is my responsibility as the parent/guardian to coordinate and provide such support as needed.

I also agree to inform the coaches of any and all health concerns or issues that might impact my child’s participation in the program, including but not limited to allergies, asthma, or any other medical conditions or behavioral concerns that may require attention.

In the event of an emergency, I authorize the program staff to seek medical treatment for my child if I am unable to be reached.

Consent & Agreement:

By signing below, I confirm that I have read and understand the expectations, rules, and waiver of liability. I agree to these terms on behalf of my child.

Parent/Guardian signature

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Speeder Kids Running Club Waiver

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