COUCH TO 5K RUN. A FOCUS 4 WOMEN CRC FALL 2017 Saturday, November 4, 2017, 9:00 a.m. to 4:00 p.m. Space is limited, so sign up soon!

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1 COUCH TO 5K RUN A FOCUS 4 WOMEN CRC FALL 2017 Saturday, November 4, 2017, 9:00 a.m. to 4:00 p.m. Space is limited, so sign up soon! Applications will be available starting Tuesday, August 1, 2017, in the EOPS Office (L 106) REGISTRATION INFORMATION & REQUIREMENTS One application per person; you cannot sign up for someone else; all fitness levels welcome Registration deadline is Friday, October 27, 2017 $10.00 non refundable registration fee per application and head ofhousehold/family required Registration fee must be submitted with the application, no exceptions! No childcare will be available, so please, no children under the age of 5 Activities will be available to children ages 5 to 10, such as the relay race, face painting, sack race, jump rope, etc. Children 11 years and up are encouraged to participate in the 5K Run To register your child(ren), we will need the following information: o Child(dren) s Name o Child(dren) s Age o Child(dren) s T shirt size o A list of child(dren) s physical limitations, if any On Saturday, November 4 th, for the 5K RUN, check in at the Recital Hall from 7:30 a.m. to 8:45 a.m. Kick off is at 9:00 a.m. sharp! For additional information or to contact us, please visit us in the Library Building (L 106) or call us at HOPE TO SEE YOU THERE!

2 COUCH TO 5K A FOCUS 4 WOMEN CRC FALL 2017 APPLICATION This application is for the Couch to 5K, which will take place on Saturday, November 4, 2017 Did you attend the 2016 Woman s Conference? YES NO Did you attend the 2017 Retreat at Wood Leaf? YES NO Did you attend the 2017 The Art of Wellness Conference? YES NO Name: ID#: Address: Telephone: address: Emergency contact Name (Print): Emergency contact telephone: Is/Are your child(ren) planning on participating in the 5K Run? YES NO Child(ren) Name: Age: Size: XS S M L XL Child(ren) Name: Age: Size: XS S M L XL Child(ren) Name: Age: Size: XS S M L XL Physical Limitations/Restrictions: YES NO If so, please indicate: : Date: FOR OFFICE USE ONLY Student s Name: Referred By: ID#: Size: XS S M L XL Paid: $10.00 Received by: Date:

3 LOS RIOS COMMUNITY COLLEGE DISTRICT AGREEMENT TO PARTICIPATE AND WAIVER/ASSUMPTION OF RISK NAME: STUDENT ID NUMBER: CLASS/ACTIVITY: INSTRUCTOR S NAME: This is a release of liability and assumption of risk agreement. Read it carefully and sign below. Completion of this form is necessary in order to participate in this class activity. I understand my decision to take this class or activity is optional and voluntary. This document cannot be altered or modified by any verbal or written statements. I am aware that participating in this Los Rios Community College District (DISTRICT) class or activity can involve MANY RISKS OF INJURY including, but not limited to, property damage, bodily injury, personal injury and death. In consideration of the DISTRICT permitting me to participate in the class/activity, I hereby voluntarily assume all risks associated with my participation and release the DISTRICT, its employees and volunteers, its colleges, campuses and centers, its governing board and the individual members thereof, and all other DISTRICT officers, agents and employees from all liability (whether based on negligence or otherwise) for injuries (including death) and damages arising out of or in any way related to the activity and/or class. I understand that if this is/involves an excursion or field trip as defined by California Code of Regulations, Section that Section states in part: All persons making the field trip or excursion shall be deemed to have waived all claims against the District or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion. All adults taking out-of-state field trips or excursions and all parents or guardians of minor students taking out-ofstate field trips or excursions shall sign a statement waiving such claims. By signing this Agreement, I hereby waive all such claims. I understand and agree to accept all the rules and requirements of the activity and/or class, including safety rules and instructions given by the supervisory personnel. I understand, and agree, and grant to the DISTRICT the right to terminate my participation in the activity and/or class within the DISTRICT s or DISTRICT s employee s sole discretion. If applicable, I understand and agree that any costs associated with my return transportation shall be at my personal expense. I consent to the DISTRICT providing emergency health assistance if it is determined necessary and further consent to the DISTRICT notifying the emergency contact (listed below) and agree that this liability release and assumption of risk agreement applies to any of the DISTRICT s actions in this regard. This agreement shall inure to the benefit of and be binding upon my heirs, decedents, successors, executors, assignees, legal representatives, and all family members. The provisions of this agreement including, but not limited to, my waiver of liability and my assumption of risk shall survive this agreement. The following person should be contacted in case of an emergency: (please print) ( ) Name Address Telephone No. I/WE, THE UNDERSIGNED, HAVE READ THIS AGREEMENT AND UNDERSTAND THAT IT IS A RELEASE OF ALL CLAIMS AND THAT I/WE ARE VOLUNTARILY ASSUMING ALL RISKS AND WAIVING ANY AND ALL CLAIMS ARISING OUT OF OR IN ANY WAY RELATED TO THIS ACTIVITY AND/OR CLASS. I/WE AGREE THAT NO ORAL REPRESENTATIONS, PROMISES, OR INDUCEMENTS, NOT EXPRESSLY CONTAINED HEREIN HAVE BEEN MADE AND THAT THIS DOCUMENT CONSTITUTES THE ENTIRE AGREEMENT PERTAINING TO THE SUBJECT MATTER CONTAINED HEREIN. SIGNATURE Date If participant is under 18, parent or guardian must sign. PARENT OR GUARDIAN Date GS 89 (L) Form Rev.7-09

4 A Focus 4 Women K Run Saturday, November 4, 2017 Attendance Agreement I understand that I am a participant in the 5K Run at Cosumnes River College (CRC). I understand that I am to conduct myself in a responsible manner and agree to the following: (Initial each, when read) I am currently enrolled at Cosumnes River College. I am aware that the California Education Code and the policies of Los Rios Community College District, prohibit possession or use of alcoholic beverages, smoke free-viper-free, or any illegal substances during the retreat, regardless of attendee s age, at any time during the retreat, including after formal activities, and all hours of the night and morning while I am under the supervision of the college. Prescription medications should be registered when turning in this form, for your own protection. Write the name(s) of your prescription on the revise side of this form. Prescription need to be in there original bottle. I understand that no inappropriate behavior will be permitted, nor any behavior that may endanger myself or others. I also understand that I am personally responsible for any damages I cause to any facility while attending this retreat and that I will not hold Cosumnes River College or Los Rios Community College District liable for any damages or injuries that occur as a result of my attendance. I agree that I will not invite any outside visitors to participate in the 5K Run activities. I understand that any infraction may result in immediate dismissal from the 5K. I also understand that further disciplinary action at Cosumnes River College may follow. All participants must stay within the designated areas announced. By signing below, I accept the rules outlined above and I fully understand that violation of any part of this agreement may result in being responsible for any expenses incurred by my retreat participation. Print Name Student ID Date:

5 LOS RIOS COMMUNITY COLLEGE DISTRICT AUTHORIZATION TO VIDEOTAPE, LICENSE, AND RELEASE OF RIGHTS I am the sole owner of all right and title in the original work ( Work ) I seek to perform at the following event: on, 20. I represent and warrant that I have the right to enter into this Authorization and Release and that the Work is original, not copied from any other work, does not infringe the rights of any third party, and is free and clear from any claim by any third party. For good and valuable consideration, I authorize the Los Rios Community College District, its colleges, Trustees, agents, officers, representatives, employees and volunteers (collectively LRCCD ), to (a) Record my likeness and voice on a video, audio, photographic, digital, electronic or any other medium; and (b) Use my name in connection with these recordings. I hereby irrevocably assign, transfer, release and convey to LRCCD, in perpetuity, throughout the universe, a nonexclusive and royalty free license to use the recordings above, as well as all intellectual property rights embodied in or pertaining to any of the foregoing and the complete right to exploit or otherwise use those recordings, in any form of medium, expression or technology now known or hereafter known or developed. I release the LRCCD and those acting pursuant to its authority from any and all liability for any violation of any personal, intellectual or proprietary right I may have in connection with such use by LRCCD. I agree to defend, indemnify, and hold harmless LRCCD, its colleges, Trustees, agents, officers, representatives, employees and volunteers from any and all liability, loss, expense (including reasonable attorneys fees and other defense and court costs) or claims imposed for damages of any nature arising out of or related to (a) the representations and warranties I have made in this document; (b) the Work, including but not limited to third party claims of copyright infringement; and (c) LRCCD s use of the Work in accordance with the Agreement. I understand that all such recordings, in whatever medium, shall remain the property of the LRCCD. I have read and fully understand the terms of this release. Name: Address: Street City, State Zip : Date: Parent/Guardian (if under 18): GS179-9/08 Date:

6 Los Rios Community College District American River College Cosumnes River College Folsom Lake College Sacramento City College Medical Emergency Consent Authorization I hereby authorize the CDC Supervisor or the designated Site Supervisor of Cosumnes River College Child Development Center to consent to any X-ray examination, anesthetic, medical, surgical diagnosis or treatment and hospital care to be rendered to this minor child, under the general or special supervision and upon the advice to a licensed physician and surgeon; or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered by said minor by a licensed dentist. I understand that the authorization I have given will be exercised only when in the judgment of the designated Supervisor it is necessary to do so. Parent, Step Parent, Domestic partner, Guardian or Foster Parent Two signatures are required if child has two adults responsible for his/her care. * This form authorizes the Child Development Center Supervisor to act under Provisions of Civil Code Section 25.8 to give consent to medical treatment on behalf of the child. ************************************************************ EMERGENCY INFORMATION Child's Name Adult Name Adult Name Birth Date Telephone Telephone PHYSICIAN TO BE CALLED IN EMERGENCY Physician's Name Telephone Address If Physician cannot be reached, what action should be taken? Medi-Cal Number Medical Insurance Insurance Number Allergies or Other Medical Limitations PERMISSION FOR MEDICAL TREATMENT. Administrative procedures vary among medical personnel and medical facilities with regard to provision of medical care for a child in the absence of the parent. The exact procedure required by the physician or hospital to be used in emergencies should be verified in advance. In case of an accident or an emergency, I authorize a staff member of the child development agency to take my child to the above-named physician or to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of the child, at my expense. Parent, Step Parent, Domestic partner, guardian or Foster Parent Two signatures are required if child has two adults responsible for his/her care. Emergency Consent [white 6/09]