"*" indicates required fields Step 1 of 6 - Athlete Information 0% EmailThis field is for validation purposes and should be left unchanged.Summer Training with Charlotte Running Co.* Price: Athlete's InformationPlease fill out all of the required fields in this section.Athlete's Name* First Last Gender* Male Female Date of Birth* MM slash DD slash YYYY School*Grade*5th6th7th8th9thFirst Time Registration?* This is the FIRST TIME my athlete has participated in any Fit180 Program Athlete HAS PARTICIPATED in a former Fit180 program. If you have already completed a registration for this athlete for a former program, you can choose to SKIP or UPDATE your Contact and Medical Information.Has Your Medical and Insurance Information Changed?* NO. My Medical Information has not Changed. Skip this section. Yes. I need to UPDATE or PROVIDE medical information This includes relevant conditions, critical allergies, over-the-counter medication, insurance and Doctor information. If nothing has changed since your last registration, please select No. Contact InformationPrimary Contact Email*For notifying parent/guardian of program changes and updates. Enter Email Confirm Email Additional Email Address (Optional)Additional contact you would like notified for program changes and updates. Enter Email Confirm Email Mother's Name First Last Mother's CellFather's Name First Last Father's CellAthlete's Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other Authorized Guardian* All authorized guardians are listed above I wish to authorize another authorized guardian for pickup/drop-off Guardian's Name First Last Cell (Additional Guardian) Medical & Insurance InfoMedical InformationPlease fill out all fields in this sectionMedical or Allergy Conditions*By signing this form, you are affirming that our child is medically and physically fit to take part in strenuous exercise. However, if there is anything we should know regarding allergies, medicine, or medical conditions, please select the second option and let us know. My child has NO medical or allergic conditions that you need to be aware of. My child has a medical or allergic condition you need to be aware of. Please list anything your child is allergic to (drugs, pollen, nuts, etc):*Does your child have any of the following? Asthma (incl. exercise-induced asthma) Diabetes Epilepsy Is your child currently taking any medications that we should be aware of?* Yes No Please list those medications:*Is there additional information we should know about your child's health or physical condition, that would affect his/her safe participation in this program?*Also use this to explain any conditions listed above. Yes No Please explain:*Insurance InformationPlease fill out all fields in this section.Name of Insurance Company*Policy Name and Number*Physician's Name* First Last Dr's Phone* Informed Consent and Terms & ConditionsAuthorization for participation and emergency treatment.* I hereby give permission for my athlete (Named Above), to participate in Fit180 Athletics programs. Further, I authorize the club to provide emergency treatment of any injury or illness my child may experience if qualified medical personnel consider treatment necessary and perform the treatment. This authorization is granted only if I cannot be reached and reasonable effort has been made to do so. My child and I are aware that participating in conditioning, track and field and cross country is a potentially hazardous activity. We assume all risks associated with participation in this sport, including, but not limited to falls, contact with other participants and other reasonable-risk conditions associated with the sport. All such risks to my child are known and understood by my child and me. We understand this informed consent form and agree to its conditions. Risk Acknowledgement and Release* I agree that by signing this form, that my minor athlete is a member of Fit180 Athletics (hereinafter “the club”), and I know that running in and volunteering for organized group runs, social events, and races associate with the club are potentially hazardous activities, which could cause injury or death. I will not allow my minor athlete to participate in any club organized events, group training runs or social events, unless he or she is medically able and properly trained, and by my signature, I certify that my minor athlete is medically able to perform all activities associated with the club and is in good health, and properly trained. I agree to abide by all rules established by the club, including the right of any official or coach to deny or suspend my participation for any reason whatsoever. I attest that I have read the rules of the club and agree to abide by them. I assume all risks associated with my minor athlete being a member of the club and participating in all club activities, which may include but no limited to: falls, physical contact with other participants/members, volunteers, race personnel, contract service providers, employees, and spectators including the potential the contraction of a communicable disease resulting from contact with other participants/members, volunteers, race personnel, contract service providers, employees, and spectators. I assume all risks including: the effects of the weather; high heat and/or humidity; freezing cold temperatures; traffic and the conditions of the road including surrounding terrain. I further agree to abide by the Center for Disease Control’s (CDC) recommendations for the prevention of the spread of the 2019 Novel Coronavirus Disease (COVID-19) and other communicable diseases, and I attest to having read the CDC’s guidance at: https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html. I assume all such risks being known, appreciated, and accepted by me. I understand that bicycles, skateboards, baby joggers/strollers, roller skates or inline skates, animals, and personal music players are not allowed in club organized runs or events, and I will abide by all rules of the club. Having read this waiver and knowing these facts and in consideration of your accepting my minor athlete’s membership, I, for myself and anyone entitled to act on my behalf, waive and release Fit180 Athletics and the Road Runners Club of America, all club sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in the club activities, even though that liability may arise out of negligence or carelessness on the part of the persons or organizations named in this waiver. In addition, I acknowledge the contagious nature of COVID-19 and other communicable diseases and voluntarily assume the risk that my minor athlete may be exposed to or infected by COVID-19 and/or other communicable diseases by participating in any activities associate with the club. I acknowledge that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 in connection with my participation in any club activities, and personally assume this risk. Image Release* In consideration of my minor child/ward being allowed to participate in any way in the Fit180 Athletics Club program, related events and activities, the undersigned agrees that such participants’ likeness may be photographed or videotaped and that such image may be published in our outlet used to promote or publicize the sports program. Terms and ConditionsCODE OF CONDUCT Parents • Be a positive role model. • Encourage good sportsmanship among all athletes. • Be supportive of coaches and meet officials. • Respect the coach’s ability to teach and coach your child. Parents may discuss the training program with coaches following practice, if time permits. It is recommended that parents schedule time separate from practice to meet with the coach to discuss concerns. • Arrive to meets at the time given to you by the coach and check in at the designated team area. • Place the physical and emotional well-being of your child above any personal desire that they have to win. • Remember, children are involved in organized sports for their enjoyment, not ours. Be supportive and encourage them to enjoy themselves and to do their best. Athletes • Arrive at practice ready to listen, work hard, learn and give my best effort. • Do your best to be at every scheduled practice. Be on time and prepared. Late athletes will not be allowed to participate in training activities without completing a warm-up. Practices will not be delayed or extended to accommodate late arrivals. • Learn the rules and always compete by them. • Be respectful of coaches, officials, parents, teammates and competitors on other teams. Treat others as you wish to be treated. • Inappropriate behavior and/or language will not be tolerated. Conduct which is not in compliance with the Code of Conduct and/or which is detrimental to the club may result in an athlete's dismissal from the club. FEES WILL NOT BE REFUNDED IN THE EVENT OF DISMISSAL CANCELLATION POLICY for all Fit180 Programs. Cancellation Fee: There will be a $20 Cancellation Fee for any refund of funds at any time after payment has been received. Maximum Refund will be: (a) If more than 48 hours prior to the start of the program, you will receive a full refund, minus cancellation fee (above), and any other expenses that have been applied, such as uniforms, race fees, etc.., or (b) if after 48 hours prior to start of the program, Maximum refund will be 50% of total program fees. Fit180 Athletics holds the right to further prorate the refund based on the actual participation of the athlete, and expenses incurred. At no time will the refund be greater than 50% of total program fees.Signature of parent or guardian*Type in your full name for an electronic signature. By signing above, you agree to the Terms and Conditions, Image Release, and Authorization for Participation as detailed above. PaymentDid you receive a unique registration code? Total Cost Credit Card* Cardholder Name Card Details Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
