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2018-2019 Running Club Permission Form
Binford Badger Running Club

Binford Elementary invites students in grades 5-6 to participate in a free, after school run club. The program will included warm ups, stretches, group runs, games, and a healthy snack. 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. If you have any questions please email Mr. Shepherd at bshepher@mccsc.edu. Deadline is Tuesday, February 12th.

WHO IS ELIGIBLE?
• Students in Grades 5th or 6th

PICK UP
Students must be picked up by 5:00pm
• Pick up will take place outside the gym doors, if we are inside due to weather, the side gym door by parking lot
• Please consider registering your child for extended day ahead of time, if you are not able to pick your child up at the ending time run club. Website: http://www.mccsc.edu/Page/356 Phone number: (812) 330-7702.

DATES
Start date February 12th and every Tuesday and Thursday for 8 weeks.

ADDITIONAL INFORMATION
• What to bring: water bottle, running shoes, and appropriate clothing
• If weather prevents the group from going outside, programming will be inside (gym, cafeteria, classrooms, hallways)
• Participant’s belongings will be stored in the gym.
• Questions?: Contact Brian Shepherd bshepher@mccsc.edu

WAIVER AND RELEASE


Email address *
Participant Name (First and Last) *
Your answer
Particpant #2 (If Applicable)
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number *
Your answer
Emergency Contact Name and Phone Number *
Your answer
Please list any allergies and relevant medical information (If none, please indicate "none"): *
Your answer
Please list any additional infomration that we should be aware of to help better serve your child:
Your answer
Pick-Up Information (Select all that apply) *
Required
If your child has permission to go home with another adult, please specify:
Your answer
Please read and agree to the following waiver and release. *
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Required
Please read and agree to the medical treatment policy. *
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Required
Please read the MCCSC video release policy. *
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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. *
Your answer
Parentes, 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. *
Your answer
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 2018-2019 Running Club program at Binford Elementary. *
Your answer
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