Serving the Youth of the Hudson Valley Since 2010 Untitled Header Image 2nd Annual DCH Youth Sports 5K Run & Kids' Fun Run
 

DCH Runners Club Registration

indicates a required answer

Registration closes on Wednesday, March 31 @ 11:59PM

1. *

Participant Name (first/last):

2. *

Age of runner as of April 2, 2021

3. *

Date of Birth (mm/dd/yyyy):

4. *

T-Shirt Size:

 (1 required)
YL AS
AM AL
AXL AXXL
5. *

Does runner have any current injuries or physical limitations or any medical conditions a coach should know about?


Use your Ctrl & Shift keys to select multiples.
6. 

If yes, please explain (list)

7. *

Medical Insurance Carrier/Policy Number:

8. *

Physician Name/Contact Number:

9. *

Parent(s)/Guardian(s) Name (first/last):

10. *

Parent(s)/Guardian(s) Cell Number:

11. *

Address/City/Zip Code:

12. *

Alternate contact person/number in case of an emergency (please include relationship to player):

Photograph/Video Permission

In consideration of participation in the DCH Sports Running program, be advised that your child/ward may be photographed and/or videotaped at a DCH Running event. The likeness of you child/ward may be published to the DCH Sports website, Facebook page, and/or Instagram site only to promote or publicize the DCH Sports Ministry.

NOTE: DCH Sports will NOT publish any participants last name.

13. *

I hereby give DCH Sports permission to publish my child's likeness to one or all of the DCH Sports media as only relating to DCH Sports.

 (1 required)
Yes No
14. *

Transportation Guidelines 

Please be aware that due to insurance guidelines the DCH Runners Club coaches are prohibited from driving an unrelated player to or from any club meet. We apologize for any inconvenience this may cause. 

Parent/Guardian Initial below (this will serve as your signature):

15. *

DCH SPORTS INC MINOR WAIVOR/RELEASE

Release of Liability for Minor Participants

READ BEFORE SIGNING

IN CONSIDERATION OF MY CHILD/WARD, being allowed to participate in any way in the DCH Sports Inc. related events and activities, the undersigned acknowledges, appreciates, and agrees that:

  1. The risk of injury to my child/ward from the activities involved in this program is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
  2. I FOR MYSELF, SPOUSE, AND CHILD/WARD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsiblity for my child/ward's participation; and,
  3. I willingly agree to comply with the program's state and customary terms and conditions for participation. If I observe an unusual significant concern in my child/ward's readiness for participation and/or in the program itself, I will remove my child/ward from the participation and bring such attention of the nearest official immediately; and,
  4. I for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS DCH Sports Inc; its directors, coaches, volunteers, other participants, sponsors, advertisers, and owners and lessors of premises used to conduct the event, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my child's/ward's involvement or participation in this program, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
  5. I, for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my child's/ward's involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INUCEMENT.

PARENT/GUARDIAN NAME (this will serve as your signature):