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GO THE DISTANCE RUNNING SCHOOL
APPLICATION
Name______________________________________________________________________________
Address___________________________________
City_______________ State_____ Zip_________
Phone(____)_______________________
E-mail____________________________________________
Gender: M_____ F_____ Age______________
School_______________________________________
T-shirt (Adult S-XL)______ Best times:
Mile_________ 5K_________ Current miles/week:____________
Medical Insurance
Company____________________________
Policy Number______________________
Parental Consent / Statement of Disclaimer
| I, undersigned, hereby certify that I am the
parent or legal guardian of the above athlete. I grant
permission for my son/daughter to attend Go the Distance Running
School. I verify that my son/daughter has had a physical
exam in the past year and is capable to participate in the
activities related to the running school. I agree to
indemnify, hold harmless, and forever discharge the Go the
Distance Running School, it’s staff, agents, or employees, The
Toledo Metroparks, and The Toledo Roadrunners for any and all
liabilities, claims, and causes of actions from injury, loss or
property damage caused to my son/daughter while at the running
school. I hereby authorize any physician or trainer
selected by the running school personnel to order and conduct
medical treatment deemed necessary. I will be responsible
for any and all costs of medical attention and treatment, except
for that covered by the running school’s excess medical policy.
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Parent/Guardian Signature
A deposit of $50 is required with this application, and will NOT be refunded
(unless enrollment is filled).
Please make checks payable to Keith Madaras
Return to: Go the Distance Running School
Attn: Keith Madaras
P.O. Box 329
Pemberville, OH 43450
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