Request edit access
2019-2020 Running Club Permission Form
Binford Badger Running Club
Binford Elementary invites students in grades 5-6 to participate in a free, after school running club. The program will include warm ups, stretches, group runs, games, and a healthy snack (provided on Thursdays). Students will meet in the gymnasium after school. Students must change clothes/shoes before, if needed.
At least two adult sponsors will be present to help supervise and lead the activities.
Registration is required as limited space is available. Please fill out the form. You must have a form filled out to participate. If you have any questions please email Mr. Shepherd at
Deadline to register is Tuesday, February 18th.
WHO IS ELIGIBLE?
• Students in Grades 5th or 6th
Students must be picked up by 5:00pm. Please be on time.
• Pick up will take place outside the gym doors.
• If you are unable to pick up your child on time, please consider registering your child for extended day ahead of time. Website:
Phone number: (812) 330-7702.
Running club will start on Tuesday February 18th, and the last practice will be on Thursday April 16th. The optional 5K is Saturday April 18th. (Running club practices are every Tuesday and Thursday).
• What to bring: water bottle, running shoes, and appropriate athletic clothing
• If weather prevents the group from going outside, programming will be inside (gym, cafeteria, classrooms, hallways)
If participant uses an inhaler or epi-pen, consider sending one with them to have on hand (as access to the school health office will not be available after school hours).
• Participants will keep their belongings in the gym or cafeteria.
• Questions? Contact Brian Shepherd
WAIVER AND RELEASE
PARTICIPANT Name (First and Last)
PARTICIPANT #2 (If Applicable)
PARENT/GUARDIAN Phone Number
Emergency Contact Name and Phone Number
Please list any allergies and relevant medical information. (If none, please indicate "none"):
Please list any additional information that we should be aware of to help better serve your child:
Pick-Up Information (Select all that apply)
I will pick my child up by 5:00.
My child has permission to walk home from the program at 5:00.
My child is enrolled in Extended Day and should go there at 5:00.
My child has permission to go home with another adult (Please specify in the next question).
If your child has permission to go home with another adult, please specify:
Please read and agree to the following waiver and release.
I have read and agree to the waiver and release.
Please read and agree to the medical treatment policy.
I give MCCSC consent to treat my child.
Please read the MCCSC video release policy.
My child has permission to be photographed.
My child does NOT have permission to be photographed.
Participant, please read the following, "I understand that this is a voluntary program and there is no fee for participation. I further understand that my child(ren) may be dismissed from the program for inappropriate behavior." Writing your name below indicates and electronic signature.
Parents, please read the following, "I understand that this is a voluntary program and there is no fee for participation. I further understand that my child(ren) may be dismissed from the program for inappropriate behavior." Writing your name below indicates and electronic signature.
Parents, please type your full name to indicate an electronic signature that you have read the running club permission slip and give your child permission to participate in the 2019-2020 Running Club program at Binford Elementary.
Never submit passwords through Google Forms.
This form was created inside of Monroe County Community School Corporation.