Dear Families,

 

Welcome to the Teens Run DC community! Please complete this online enrollment form so that your child may participate in Teens Run DC’s sports-based youth development program!

 

What is Teens Run DC?

Teens Run DC uses physical activity and mentoring to develop life skills in middle and high school students. The program is free and open to youth of all fitness levels and abilities.

 

Weekday Enrichment Program

  • Youth participate in fitness & life skills sessions with TRDC coaches and school staff.
  • Youth attend at least 3 weekend races throughout the year.
  • Program is available to youth at specific TRDC partner school sites.

 

Weekend Mentoring Program

  • Youth attend running practice on Saturday mornings and run races throughout the year.
  • Youth are paired with trained mentors who have undergone background checks.
  • Program is available to all DC area youth. Families are also welcomed to attend practices and events!

 

Questions?

  • Contact Director of Programs Jen Edmond at 202-818-8600 ext. 1 or jen@teensrundc.org. For the School Enrichment Program, you may also contact the TRDC coach at your child's school or program site.
  • Visit our website at www.teensrundc.org. Check out our calendar for information on upcoming programs and events.

 

Enrollment Checklist

In order for your child to participate in Teens Run DC programming, please complete this online enrollment form in its entirety. The enrollment form is broken into the following three sections:

  • Youth Enrollment Form (Youth Information, Parent Information, & Emergency Treatment Information)
  • Waiver of Liability (Parent/Guardian signature required)
  • GW University Research Consent Form

YOUTH ENROLLMENT FORM

Youth Information

School- Other
Date of Birth (MM/DD/YYYY)*
Ethnicity (Other)
Primary Language
Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Youth's Email*
Confirm Email*
Youth's Phone #*

Parent/Guardian Information

Parent/Legal Guardian Name (First & Last)*
If "other", please indicate relationship of legal guardian to student
Parent/Legal Guardian Street Address*
Parent/Legal Guardian Zip Code*
Parent/Legal Guardian Primary Phone*
Parent/Legal Guardian Cell/Alternate Phone*
Parent/Legal Guardian Email*

Emergency Treatment & Medical Information

Emergency Contact Name*
Emergency Contact Relationship to Youth*
Emergency Contact Phone*
Youth's Allergies/Medical Conditions (physical & mental health; if none, please enter "N/A")*
Youth's Medications (If none, please enter "N/A")*
Insurance Company
Insurance Policy #
Policy Holder's Name

RELEASE OF LIABILITY, WAIVER OF CLAIM & ASSUMPTION OF RISKS AGREEMENT

(This document affects your legal rights and the rights of your child. By signing this document, you will waive certain legal rights, including the right to sue or claim compensation following an accident, injury or death.  You must read and understand it before signing it).

 

Acknowledgment of Relationship:  I hereby certify that I am the parent or legal guardian of the minor child listed in this enrollment packet (my “Child”).

 

Permission to Participate, Including Transportation and Race Entries: I hereby voluntarily grant permission for my Child to participate in all activities conducted by Teens Run DC (“TRDC”), including TRDC activities at TRDC program sites and field trips and activities away from TRDC program sites. This permission extends to transportation to any such activities and events. I give permission to TRDC to register my Child for TRDC races and events and sign as guardian for my Child on the entry form of TRDC races and events.

 

Evaluation Consent: I give permission to TRDC to collect and record data, including running/walking pace data and surveys, about my child with the understanding that all information obtained will remain private, and that any responses publicly reported will be grouped together with other participants of this program and that my child will not be individually linked to his/her response. Only the staff approved by TRDC will be able to view his/her responses.

 

Understanding of Activities and Medical Certification: I, the undersigned participant, acknowledge and grant permission for my Child to participate in the TRDC Program. I certify that my Child is medically and physically fit to participate in TRDC, and has not been advised otherwise by any person (including any medical personnel). My Child is in good health and has no medical or other physical condition or impediment that would endanger him/her if he/she participates in any TRDC activities. I further acknowledge and understand that TRDC strongly recommends that he/she get a physical from a health care provider prior to participation in the program.

 

Assumption of Risks: I, on my own behalf, on behalf of my Child and on behalf of anyone authorized to act on behalf of my Child, understand and acknowledge the risks of injury to my Child from the TRDC program and from the transportation associated with the program, that running is a potentially hazardous activity and that potential risks include, but are not limited to, falls, contact with other participants, the effects of weather, including high heat and/or humidity, the conditions of the road and traffic on the course, all such risks being known and appreciated by me.  I understand, acknowledge and agree that my Child should not enter or run in these activities unless he/she is medically able and properly trained. I, on my own behalf, on behalf of my Child, and on behalf of anyone authorized to act on behalf of my Child, agree to abide by any decision of a race official relative to his/her ability to safely complete the run. I further understand and acknowledge the risk of accident serious injuries and death from the transportation to be provided through TRDC. I, on my own behalf, on behalf of my Child and on behalf of anyone authorized to act on behalf of my Child, understand, acknowledge and voluntarily assume all risks associated this Program, both known and unknown, identified or unidentified, anticipated or unanticipated, even if arising from the negligence of any Teens Run DC or its agents, employees, members, managers, officers, directors, all volunteers, sponsors, organizers, independent contractors, affiliates, predecessors, successors, and any promoting organization(s), medical providers, property owners, law enforcement agencies, all public entities, special districts, and properties (and their respective shareholders, agents, officials and employees) or others, and I assume full responsibility for my Child’s participation.

 

Release of Liability/Waiver of Claims:  As lawful consideration of my Child’s acceptance into the TRDC program and the right to engage as a participant in any way in TRDC programs, related events and activities, I, on my own behalf, on behalf of my Child, and on behalf of anyone entitled to act on my Child’s behalf, acknowledge, agree and promise that I will not make a claim of any kind, including but not limited to a claim for personal injury, property damage and/or wrongful death, against TRDC, DCPS, its agents, employees, members, managers, officers, directors, all volunteers, sponsors, organizers, independent contractors, affiliates, predecessors, successors, and any promoting organization(s), medical providers, property owners, law enforcement agencies, all public entities, special districts, and properties (and their respective shareholders, agents, officials and employees) (collectively, the “RELEASEES”) through or by which the programs, related events and activities occur. 

 

This agreement is intended to discharge in advance RELEASEES from and against any and all liability asserted by me individually and on behalf of my Child, our heirs, assigns, legal representatives, executors, administrators, successors in interest, estate and next of kin (hereinafter collectively our “Successors”), including liability for negligence arising out of, or connected in any way, with my Child’s participation in the Teens Run DC.  I further agree to indemnify and hold harmless RELEASEES from any liability, claim, or action for personal injury, property damage, wrongful death which arises out of or related to participation in the program, whether or not the liability, claim, or action, arises out of the negligence and carelessness on the part of RELEASEES.

 

Consent to Medical Treatment: In the event of a medical necessity or emergency, I hereby authorize the adult representative of Teens Run DC and/or TRDC’s partners, including DCPS, to make any necessary arrangements for the proper medical or surgical care of my Child, and to give the required consents in connection therewith. I further authorize any medical, dental, and/or emergency personnel selected by such adult representative to secure and provide necessary and proper medical treatment my Child. I also give consent for my child to be transported by ambulance to an emergency center for treatment. I understand that I will be notified as soon as possible in the event an emergency arises requiring medical assistance, and I assume all financial responsibility for any medical treatment (including transportation) for my Child.

 

Media Release: I give consent for my Child to be photographed, audio recorded, or video recorded as part of TRDC. I give permission for these photographs, audio recordings, and videos to be used in non-commercial radio, television, internet, or print media reports and/or media campaign(s) resulting from participation in the program and its activities, including annual reports, newsletters, brochures, and/or other media outlets. I understand that my Child and I will receive no compensation for his or her appearance in these non-commercial media campaigns. I further agree that TRDC partners and the sponsors of any TRDC event may use my Child’s name and likeness for publicity purposes.

 

Entire Agreement:  I agree, for myself, my Child and our Successors, that the above representations are contractually binding, and this RELEASE OF LIABILITY, WAIVER OF CLAIM AND ASSUMPTION OF RISKS AGREEMENT may not be modified orally.  I agree that this agreement will be governed by the laws of the District of Columbia.  I understand that this is the entire agreement between TRDC and me and that it is for the benefit of all Releasees. My signature below indicates that I have read this entire document, understand it completely, and agree to be bound by its terms.

 

AcknowledgmentI have carefully read and understand the terms of this Release of Liability, Waiver of claims and Assumption of Risks Agreement.  I understand that this is a legally binding document and that I am giving up substantial legal rights by signing this Release of Liability, Waiver of claims and Assumption of Risks Agreement, and I sign it freely and voluntarily without any inducement or anyone forcing me to participate in the Teens Run DC Programs and Activities.

 

I/we, legal parent/guardian(s) of the minor child listed in this enrollment packet agree to the terms listed in the above agreement and hereby certify that the statements in this enrollment form are correct and true.

Parent/Legal Guardian Electronic Signature*
Waiver of Liability Signature Date (MM/DD/YYYY)*

GW UNIVERSITY RESEARCH CONSENT FORM

IRB 021120 Approval Date: April 7, 2017


Dear Parent/Guardian of Teens Run DC Program Participant:


We welcome you and your child to the Teens Run DC (TRDC) Program. I am a researcher at the George Washington University (GWU) and my research team and I work closely with the TRDC program staff to evaluate the impact of student involvement in this mentoring and distance running program on his/her health and academic outcomes. I hope to seek your permission to allow your child to participate in our study, Evaluating the health, mental health, and academic outcomes associated with TRDC.


If you agree, your child will be asked to complete a number of questionnaires that measure: 1) how connected they feel to their peers, school, community, and home, 2) their ability to problem-solve and reach goals, 3) their emotional and behavioral well-being, and 4) a few weeks into the program your child will be asked how they feel about the mentoring relationship with their primary mentor and with the broader TRDC community. They will also be asked their height and weight in order to determine if program participation is related to any physical changes. Although it is unlikely, if there are any significant concerns about the responses provided in the surveys, the TRDC research team, led by Dr. Olga Acosta Price, will inform the TRDC Program Director, Steve Hocker, who will then share these general concerns with your child’s school counselor (no actual responses will be shared), to assess your child’s needs and determine appropriate follow-up with you. In addition, we separately ask permission to obtain all of your child’s school attendance, grades, and graduation records for every year enrolled in DCPS from the Office of Data and Strategy, DCPS, in order to assess school performance. We will request information for every year your child is in the program. Furthermore, at the end of the school year your child may be asked to voluntarily participate in a focus group that will help us understand program strengths and weaknesses.


Students who agree to participate in the program evaluation activities will be asked to do so when they start the program and at the conclusion of the year in order to assess how much they have changed from program start to end. Completion of questionnaires will take students approximately 30-60 minutes for each administration and involvement in focus groups will not exceed 1.5 hours. There are no significant risks involved with the evaluation process, but there are remote risks of loss of confidentiality and emotional discomfort while answering questions. If a student is uncomfortable with any question he/she does not have to answer it. Participation in all data collection activities is voluntary and student may choose to withdraw from the study at any time. Withdrawal from the research aspect of the program will not have any negative consequences on their program involvement. All information obtained directly from the students at any point in time will remain confidential and viewed only by the research team and the Program Director. All confidential information will be entered into a database that will not include your child’s name.


The paper copies of the questionnaires and academic records will be stored in a locked filing cabinet at GWU and will be shredded at the conclusion of the study. Any information shared publically will not identify any student individually. Please be aware that under the Protection of Pupil Rights Act, 20 U.S.C. Section 1232(c)(1)(A), you have the right to review a copy of the questions asked or materials that will be used with your children. Please contact Dr. Olga Acosta Priceat (202) 994-4848 or oaprice@gwu.edu to do so. If you have additional questions about your or your child’s rights please contact the GW Office of Human Research at ohrirb@gwu.edu or 202-994-2715. You also have the right to inspect, review and challenge the contents of any academic records before signing this form.


Please sign below to indicate your level of approval (CHECK ONE) for EACH statement:

GW Questionnaires*
  • I agree to allow the TRDC research team to collect questionnaires from (me/my child) throughout the course of (my/their) involvement in the program.
  • I DO NOT agree to allow the TRDC research team to collect questionnaires from (me/my child) throughout the course of (my/their) involvement in the program.
Signature (Parent/Legal Guardian if student is not yet 18 OR Student if 18 or older)*
Date Signed (MM/DD/YYYY)*
GW Attendance*
  • I give permission to have all of (my/my child’s) school attendance, grades, and graduation records for every year I am/your child is enrolled in DCPS, shared with the TRDC research team as of the date by my signature below and for the purposes stated in the notice above. I certify that I am the student named below and that I have reached the age of 18 or that I am the parent of the student named below and he or she has not reached the age of eighteen (18).
  • I DO NOT give permission to have (my/my child’s) school attendance, grades, and graduation records shared.
Signature (Parent/Legal Guardian if student is not yet 18 OR Student if 18 or older)*
Date Signed (MM/DD/YYYY)*
GW Focus Groups*
  • I give permission to allow (myself/my child) to participate in focus groups with the TRDC research team.
  • I DO NOT give permission to allow (myself/my child) to participate in focus groups with the TRDC research team.
Signature (Parent/Legal Guardian if student is not yet 18 OR Student if 18 or older)*
Date Signed (MM/DD/YYYY)*
Name of Student*
Student's Date of Birth*

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