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Bathsheba McLaughlin
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Mankato Family YMCA STRIDE and STRIDE TOO Participant Registration February 11, 2019 May 2, 2019 Participant Name: Birth Date: Grade: Home Address: City: State: Zip Code: School: T-Shirt Size: Youth

1 Mankato Family YMCA STRIDE and STRIDE TOO Participant Registration February 11, 2019 May 2, 2019 Participant Name: Birth Date: Grade: Home Address: City: State: Zip Code: School: T-Shirt Size: Youth M (size 10/12) Youth L (size 14/16) Adult S Adult M Adult L Adult XL Adult XXL Parent/Guardian Information Name: address*: Work phone: Cell phone: Home phone: Name: address*: Work phone: Cell phone: Home phone: * addresses will be used for weekly communication from STRIDE Director & Coaches and other YMCA messages. Program Site/Locations: Check One Location Start Date Session Days Times Transportation *Mankato YMCA 1401 S. Riverfront Drive Mon/Wed Walking escort will be provided from Roosevelt. Bussing available from Jefferson, Washington, Immanuel, and Rosa Parks. *Mankato YMCA 1401 S. Riverfront Drive Walking escort will be provided from Roosevelt. Bussing available from Jefferson, Washington, Immanuel, and Rosa Parks. Franklin Site TBD TBD, walking escort will be provided if needed. Monroe/Bridges Site TBD TBD, walking escort will be provided if needed. **River Ridge Church 354 Carol Court, N. Mankato Walking escort from Hoover. **Crossview Covenant 2000 Howard Drive, N. Mankato Grades 6-8 (STRIDE TOO) Walking escort from Dakota Meadows. Drop off site for MAC. **Saint Peter Com. Center 600 South 5 th St, St. Peter Grades Mon/Wed Afterschool-3:20 Pickup: 4:50-5pm Transportation available to the Community Center. *YMCA Sites: Please indicate where you will pick up your child: (Boys going to the Pepsi Rec Room will not be under program supervision after STRIDE) Pepsi Rec Room or Lobby **All other sites: When program is released, how will your child be picked up?: Parent pick-up or Walk/bike home

2 STRIDE Fees & Information: Program Fee: $ This fee covers the entire cost of the 10 week program including: a snack for each session, program shirt, STRIDE water bottle, and participant entry in the end of season 5K walk/run event. Reduced Fee/Financial Assistance is available. For information please contact: Molly (507) Ext. 233 or mambrose@mankatoymca.org. Transportation: YES, I need bus transport to STRIDE (Included for some schools to YMCA **Transportation is not guaranteed, bussing is on a first come first serve basis and based on spots available.**) NO, my child will walk (with coach/escort) to STRIDE or I will provide my own transportation. Emergency and Health Information: IN CASE OF ACCIDENT OR ILLNESS, NOTIFY (Parents will be notified first; please list alternative contact): Name (other than parent): Relationship: Phone/cell: Allergies (please list all allergies participant has experienced): Medications (please list any all medications participant is currently taking, and see last page if medication needs to be administered during program): Special Health Needs/Concerns:

3 MANKATO FAMILY YMCA Release and Waiver of Liability and Indemnity Agreement I am signing this Agreement because I want my child(ren), if any, as named below and me to use the facilities, services, or programs of the Mankato Family YMCA (the YMCA ) or because I want the opportunity to provide services to or for the YMCA as a volunteer. In consideration for being permitted to utilize the facilities, services, and programs of the YMCA, or provide services to or for the YMCA as a volunteer, for any purpose, including but not limited to observation or use of facilities or equipment, or participation in any program affiliated with the YMCA, without respect to location, I, for myself, my child(ren) named below, and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that I have, or immediately upon entering or participating, will inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated programs have been inspected and carefully considered and that I find and accept same as being safe and reasonably suited for the purpose of such observation, use, or participation. In further consideration of the opportunity for myself or my child(ren), if any, named below, to participate in programs or activities of the YMCA, or for me to provide services to or for the YMCA as a volunteer, whether on YMCA premises or elsewhere: I HEREBY RELEASE, WAIVE, AND DISCHARGE, both for myself and my child(ren), any and all claims or demands against AND COVENANT NOT TO SUE the YMCA, its directors, officers, and employees ( RELEASEES ) for injury to or death of me or my child(ren), damage to my or my child(ren) s property, or loss of companionship or affection, whether caused by the negligence of RELEASEES or otherwise, that arises or results from my or my child(ren) s use of facilities, services, or programs of the YMCA or my volunteer service to or for the YMCA including, but not limited to, 1) an act or omission by RELEASEES, negligent or otherwise; 2) malfunction or break in equipment or facilities; 3) maintenance of any equipment or facilities, 4) instruction or supervision by RELEASEES. I fully understand the risk of injury to or death of me or my child(ren) or that of others and of damage to property mine, my child(ren) s, or others that might result from my or my child(ren) s use of the facilities, services, or programs of the YMCA or my volunteer services to or for the YMCA. Nonetheless, I ASSUME FULL RESPONSIBILITY FOR THAT RISK, whether due to negligence of RELEASEES or otherwise. My child(ren) and I are in good health, and I know of no reason why my child(ren) or I are not capable of using the YMCA s facilities, services, or programs or I am not capable of providing volunteer services to or for the YMCA. I ALSO AGREE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS the RELEASEES from and against any claim for injury to or death of persons, damage to property, or other loss, including without limitation claims asserted by other participants in YMCA programs or activities and members of the public, that the RELEASEES may incur due to my or my child(ren) s use of YMCA facilities, services, or programs, or my volunteer service to or for the YMCA, regardless of whether such claims result from the negligence of the RELEASEES or otherwise. This indemnity shall survive my and my child(ren) s use of any or all YMCA facilities, services, or programs and the completion of any volunteer services I may provide the YMCA. I INTEND THAT THIS AGREEMENT BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAW OF THE STATE OF MINNESOTA. IF ANY PORTION IS HELD INVALID, I INTEND FOR THE BALANCE TO CONTINUE AND REMAIN IN FULL LEGAL EFFECT. I HAVE READ THIS REALEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, HAVE SIGNED IT VOLUNTARILY, AND FULLY UNDERSTAND ITS MEANING. THIS AGREEMENT SHALL REMAIN IN EFFECT UNTIL I DELIVER A WRITTEN CANCELLATION TO THE YMCA. I HAVE READ AND UNDERSTAND THIS DOCUMENT AND RELEASE. I understand my photo may be used in Y promotions, and they may send messages/promotional content periodically to me by I certify that all participants listed above are in normal health and capable of safe participation in YMCA recreation programs. 2. I hereby authorize the YMCA to provide transportation for my child and me to and from the YMCA program if necessary. 3. In the event that I cannot be reached in an emergency, I authorize the YMCA staff to provide and obtain medical treatments for my child. 4. I give permission for the Mankato Family YMCA to use any suitable photographs and/or quoted statements by my child or me for the purpose of promotion and advertising of the Mankato Family YMCA and its programs. I understand that there will be no paid compensation for any such usages. 5. In consideration of my child s participation in the activities of the Mankato Family YMCA and its respective officers, employees and members, including but not limited to its or their own negligence, and do hereby for myself, heirs, executors and administrators, waive, release and forever discharge any and all rights and claims for damages which may have or which may hereafter accrue to my child arising out of or connected with participation in any of the activities of the Mankato Family YMCA, use of its facilities, or use of equipment within its facilities. Printed Name of Child Signature of Parent/Guardian Printed Name of Parent/Gaurdian Date

4 End-of-season STRIDE 5k run/walk information and release form: Organized by Girls on the Run, YWCA Date: Saturday, April 27, 2019 Time: 10:00 am Location: Spring Lake Park, North Mankato CONSENT TO PARTICIPATE IN EVENT I agree to participate in the YWCA Girls on the Run 5K Event as a runner. I acknowledge that there are inherent risks in participating in the Event and that I am participating at my own risk. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, other volunteers, spectators, coaches, event officials, and directors of the 5K Event. Physical reactions to exercise may include heat-related illness, abnormal heartbeats and blood pressure and, in rare instances, events such as heart attacks. While the YWCA Mankato takes all reasonable precautions, we can make no guarantees regarding these and other risks. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them, or because of their possible liability without fault. I hereby assume all of the risks of participating. Recognizing the risks of the 5K event, and in consideration for allowing participation in the 5K event, I hereby release, discharge and agree to hold harmless, and to indemnify the YWCA Mankato, the City of North Mankato, and Girls on the Run International, their owners, directors, officers, contributors, sponsors, employees, contractors, agents, and assigns against and from any and all causes of action, claims, demands, damages, costs, loss of services, expenses, compensation, all consequential damages and attorneys fees (regardless whether pursuant to the laws of any county, state, or country) claimed by, through, or on behalf of me related directly or indirectly to the 5k race, and specifically including any and all claims for personal injuries sustained while participating in the 5K event without regard to negligence or negligent conditions. (continued on next page) CONSENT TO MEDICAL TREATMENT I hereby authorize YWCA Mankato, if after a reasonable attempt has been made to reach a parent, guardian or emergency contact to obtain consent, or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment, and hospital care, to be rendered to me under the general or special supervision and on the advice of any physician or surgeon who may treat me, and consent to any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment and hospital care, to be rendered to me by any health care professional who may treat me. I agree to pay for any such treatment and to reimburse YWCA Mankato for all costs and expenses it may incur related to such treatment. PHOTO RELEASE I understand that at YWCA Girls on the Run events and activities, I may be photographed and/or filmed. I hereby grant YWCA Mankato, Girls on the Run of Greater Mankato, Girls on the Run International, its National Title Sponsors, its National Sponsors, and any 5k sponsors and all assigns, licensees, successors in interest, legal representatives, employees, consultants, and those acting with permission or authority of the aforementioned parties, the absolute, irrevocable and unrestricted right to use photographs, videos likenesses and audio recordings (including without limitation all originals, negatives, prints and transparencies or any duplicates or reproductions of the foregoing) that have been or will be taken of me (collectively, Images ), in which I may be included with others, to copyright the same, in the name of Girls on the Run or otherwise; to use, re-use, publish and republish the same in whole or in part, individually or in conjunction with other photographs and videos, and in conjunction with any printed matter, in any and all media now and hereafter known, and for any purpose whatsoever; and to use my name in connection herewith. I hereby release and agree to hold harmless YWCA Mankato and all aforementioned entities, from any damages or liability relating to or arising from any use of or modification, alteration, distortion or other change to any of the Images and/or information gathered, unless it can be proven that such reproduction were maliciously caused, produced and published for the sole purpose of subjecting me to conspicuous ridicule, scandal, reproach, scorn and indignity. I hereby waive any claims I may have based on any usage of the Images, information gathered, or works derived thereof, including but not limited to claims for either invasion of privacy or libel. RELEASE OF LIABILITY I expressly agree that this consent is intended to be as broad and inclusive a release of liability as permitted by applicable law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I hereby warrant and represent that I am 18 years old or older or, if applicable, that I am the parent or legal guardian of the child under the age of 18 years old who I am registering to participate in the event and that I have the full power and authority to agree to these terms on behalf of such child, and to bind him/her to these terms. I have carefully read this consent and agree to its terms and conditions, that before signing this agreement I had the chance to ask questions; and I am aware that by signing this consent, I assume all risks and waive and release certain substantial rights that I may have or possess against YWCA Mankato and Girls on the Run International. To the extent permitted by applicable law, I hereby irrevocably and unconditionally waive trial by jury in any legal action or proceeding related to this agreement. STRIDE Participant s Name: Signature of Parent/Guardian: Date:

CONSENT FORM FOR ADMINISTRATION OF MEDICATION DURING A YMCA PROGRAM!!! Before any medication is administered by YMCA personnel, this form must be completed and on file!

5 CONSENT FORM FOR ADMINISTRATION OF MEDICATION DURING A YMCA PROGRAM!!! Before any medication is administered by YMCA personnel, this form must be completed and on file!!! Child s Name Birth Date Home Address School Grade PHYSICIAN S ORDER I have prescribed the following medication for this child and request the dosages given during program hours be administered by YMCA personnel. Medication: Dosage and Time: Instructions for giving medication: Possible side effects: Diagnosis/Medical reason for medication: Inhaler or Epl-Pens: has child received instruction and permission for self-administration: Yes No PHYSICIAN S SIGNATURE: DATE PRINT NAME: Office Address: Phone: FOR PRESCRIPTION MEDICATION: PARENT/GUARDIAN AUTHORIZATION I request this medication be given as prescribed and give permission for the YMCA Staff and Physician to exchange information regarding this medication and the diagnosis for which it is prescribed. I release YMCA personnel from any liability in relation to the administration of this medication at the YMCA. I will provide this medication in the original, properly labeled pharmacy bottle. I will provide a medication discontinuation order from the physician if medication is stopped. PARENT/GUARDIAN DATE FOR NON-PRESCRIPTION MEDICATION: Medication: Purpose for giving medication: Amount to be given: Frequency: I release YMCA personnel from any liability in relation to the administration of this medication at the YMCA. I understand I must provide this medication in the original, properly labeled bottle/container. PARENT/GUARDIAN DATE

SUMMER YOUTH PROGRAMS 2018 PARTICIPATION INFORMATION FORM

SUMMER YOUTH PROGRAMS 2018 PARTICIPATION INFORMATION FORM Personal Information Child s Name Age of Birth Parent/Legal Guardian 1 Phone Parent/Legal Guardian 2 Phone Address Alternate Phone work cell other