Girls Thrive Registration Form
Participant’s Name:
Session Dates: Spring/Fall (circle one) Year:
Participant’s Age, School, and Grade:
Parent/Guardian Name:
Address: Street
City
Phone: Cell
Zip
Home
Parent/Guardian Email:
Work
Participant Email:
Primary Emergency Contact: Name
Phone
Secondary Emergency Contact (not living with you): Name
Other people
authorized
to pick up
participant:
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Please check one or both: my child will participate in
Running (Tues & Thurs)
Biking (Sat)
Cost*: $75
Scholarship Needed: Yes/No (circle one) Amount:
Adult Shirt Size: S/M/L/XL (circle one)
Does your child need to borrow a bike and/or helmet?
If yes, please provide height and weight:
Health Information: Please provide information on any serious health conditions that could impact
your child’s ability to participate in the program
Allergies?
Asthma?
Does your child carry an inhaler or EpiPen?
Name of Doctor:
Phone number of Doctor:
Media Release: By signing below, I give Girls Thrive (GT) permission to use photos, videos and the first
name of my child on the GT website, brochures, social media and other publications.
Parent/Guardian Signature:
Date:
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Warning: Serious, catastrophic, and perhaps fatal injury may result from participation in any sport,
athletic or recreational activity or physical exercise. I have enrolled my child in the Girls Thrive program
and I know, understand and appreciate the nature of this program and its activities, the benefits to
expect, the discomforts, dangers and inherent risks involved in participation. I fully know and
understand that participation is voluntary, at my own risk, and I am free to discontinue my child’s
participation at any time. I have notified Girls Thrive leaders about any of my child’s health concerns and
take full responsibility for such concerns. I hereby release Girls Thrive Inc and the people involved with
Girls Thrive Inc (volunteer coaches, instructors, etc.) from any liability for any claims, demands, injuries,
actions, or causes of actions to my person or property arising out of or connected with the use of any of
the services, equipment, or facilities provided by Girls Thrive Inc and those individuals involved with
Girls Thrive. I have carefully read with a full, definite, and clear understanding the foregoing provisions
and freely enter into the within agreement of the waiver/release.
Parent/Guardian Signature:
Date:
* Cash and checks are accepted for the registration fee. Please make checks payable to Girls
Thrive. Registration forms can be emailed to [email protected]. The registration form and
payment can be mailed to: Girls Thrive, c/o Blair Haseman, 2001 Gold Rush Ave., Helena, MT
59601
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