Emergency Contact Information:

Does your child have any of the following allergies:

______ Hay Fever
______ Poison Ivy
______ Insect Stings
______Penicillin
______ Other (Specify)____________________

Does your child suffer from:

Asthma ______
Diabetes______
Other_______ (Specify)___________________

Has the athlete had any operations or serious injuries _________ (If Yes please specify)
______________________________________________________________________________
______________________________________________________________________________

Is there an important information we should know?_______ (If Yes please specify)

______________________________________________________________________________
______________________________________________________________________________

Parent’s Name:_______________________________
Parent’s Email:_______________________________
Parents Phone #:______________________________
Parent’s Secondary Phone #:_____________________________
Emergency Contact:___________________________
Emergency Contact Phone#:____________________
Athlete’s Primary Physician:______________________________
Primary Physician Phone #:______________________________

2011 Keoneula Running Club Medical/Legal Waiver

I/we as the legal guardian/parent(s) of:

______________________________________________________________________
(Athlete’s Name)

certify by signing below that all health history provided on this form is accurate and certify that the above mentioned athlete has
written permission from their physician to participate in this sport. I understand that running is a strenuous sport and that injury to
the athlete could occur. By signing this form I agree to unconditionally release, acquit, and forever discharge The Keoneula Run-
ning Club and its program director, coachs and volunteers of any and all liability and waive the right to bring any form of legal
action or claim against The Keoneula Running Club and
its program director/coaches/volunteers for any injury sustained during any club practice, competition, or event.
I also understand that the program director, coaches and volunteers of the Keoneula Running Club are safety conscious and will
follow appropriate safety procedures. In the event of an injury or illness to the athlete the program director, coaches and volun-
teers of The Keoneula Running Club will make every effort to contact the parents/guardians/emergency contact of the athlete
listed on this form. In the event of an EMERGENCY if contact cannont be made with the athletes parent(s)/legal guardian/
emergency contact I hereby give permission to the physician selected by The Keoneula Running Club, to hospitalize, secure
proper treatment for and to order injection, anesthesia or surgery for my child as prescribed by the physician.

This agreement and waiver, having been thoroughly read and understood, is voluntarily signed and agreed to by:

_________________________________________ ________________

Parent’s Signature Date