Girls On The Run of Nebraska

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Assume you are registered for the team you choose unless you are notified differently.

GOTR teams meet at the front door of the school on the first day of practice, unless you are notified of special arrangements.

Rainy/Snowy Weather — GOTR teams will meet regardless of the weather, UNLESS the schools close.

Payment
This form is for people who would like to register their daughter online. Please fill in the appropriate information below and click the continue button at the bottom of the page. Step 5 in this process will take you to PayPal for your payment information. You can use your PayPal account, if you have one, or any major credit (no PayPal account is required). If you do not want to pay online please download the registration form and mail in when completed.

If you don’t see a particular school/site listed in the drop-down menu below, it means that school doesn’t host a GOTR team or that team is already full. E-mail girlsontherun@neb.rr.com for more information.

Step 1 of 5: Enter Participant Information:

*Girl's First Name:

*Girl's Last Name:

*Address:

Address 2:

*City:

*State:

*Zip: 5 digits only

*Phone: 000-000-0000

*Birthdate: YYYY-MM-DD

Ethnicity:
Optional, but helpful for grant funding.

*Girl's School Name:

*Girls on the Run Program Site:

*Girl's Grade in School:

*Girl's T-shirt size:

Has your daughter participated in Girls on the Run before?

Where does your daughter go after Girls on the Run, and how does she get there? (home, tutor, after-school program, grandparent's house — walk, bike, carpool.)

Step 2 of 5: Enter Parent/Guardian & Emergency Information

*Parent/Guardian First Name:

*Parent/Guardian Last Name:

*Parents Address:

Parents Address 2:

*City:

*State:

*Zip: 5 digits only

*Email:

*Phone: 000-000-0000

Parent/Guardian Alternate Phone:

Employer:
Optional, but may be very helpful in securing grants or sponsorships.

Occupation:
Optional, but may be very helpful in securing grants or sponsorships.

Emergency Contact Information

*Emergency First Name:

*Emergency Last Name:

*Relationship to Girl:

* Emergency Phone: 000-000-0000

Emergency Alternative Phone:

Step 3 of 5: Enter Health Information

Girl's Pediatrician:

Phone:

Family Medical/Hospital Insurance

Policy/Group Number:

Health History
(please check if yes)

Heart disease or heart problems

Hypertension-high blood pressure

Diabetes or abnormal blood sugar test

Epilepsy or seizures

Abnormal chest x-ray

Orthopedic or muscular problems

Stroke

Asthma

Any other major health problems or allergies? (if yes, please list)

Use of prescription drugs?
(if yes, please list)

Does child live with or spend a lot of time with someone who smokes cigarettes?

Yes
No

Does child have close relatives (mother, father, brother, sister) who have a history of heart disease?

Yes
No

Step 4 of 5: Waiver and Permission

WAIVER OF LIABILITY AND PERMISSION TO PARTICIPATE
I, the undersigned, give permission for my child to participate in the activities offered by Girls on the Run of Nebraska I understand there are inherent risks associated with physical activity. To the best of my knowledge, there are no contraindications to my daughter’s participation in Girls on the Run or the season-ending 5K.

By my acceptance/electronic signature below, I give permission for my daughter to participate in this program and the 5K. I assume, on behalf of my daughter, all risk associated with the program and the 5K, including but not limited to: falls, contact with other participants, the effect of the weather including high humidity, and any traffic or unnatural conditions of the practice area or road race course, such as rough surfaces or motorists.

I waive and release Girls on the Run of Nebraska, all coaches, all sponsors, race officials, their representatives and successors from claims and liabilities of any kind arising out of my dependent’s participation in any way in the program, activities and the 5K event, though that liability may arise out of the negligence or carelessness on the part of the persons named in the waiver.

Further, if said participant should become injured while participating in a program, I authorize transportation to any physician or surgeon licensed in the State of Nebraska to perform emergency or surgical treatments, which, in his or her judgment, may be necessary.

I understand that Girls on the Run of Nebraska conducts evaluations to assess the quality of programs. I give permission for my child to be part of this program evaluation. I also understand that the information collected about my child will be kept confidential and that only the persons connected with Girls on the Run of Nebraska and the evaluation staff will have access to this information.

I also give permission for any photograph, videotape, film audiotape or writing of said participant, obtained during normal after-school activities, to be used in informational materials for Girls on the Run of Nebraska.

I accept

PERMISSION TO PROVIDE NECESSARY TREATMENT OR EMERGENCY CARE
I hereby give permission to the medical personnel selected by Girls on the Run of the Nebraska, including without limitation, coaches, volunteers and staff to provide transportation and all necessary medical and dental care for the above-named child. I hereby give permission to the medical care provider(s) selected by Girls on the Run of the Nebraska to secure and administer all necessary treatment, including hospitalization, for the child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of the child.

I accept

Electronic Signature:
Please re-type your first and last name exactly as you entered it above.

*Parent/Guardian First Name:

*Parent/Guardian Last Name: