COMPLETE THE CAMP APPLICATION
Elite Pole Vault Camp
Gold Medal Pole vault Camp
ATP + Gold Medal Pole Vault Camp
Print the forms below and send in with your camp deposit.
Make cashier's check or money order for non-refundable deposit(see above section for deposit amount) or payment in full payable to Pole Vault U and mail to:
c/o Rick Attig
10104 Sunset Dr.
Lenexa, KS 66220
MEDICAL HISTORY (to be completed by the parent)
Is there a know history of:
A. Birth deformities? Yes_____No_____
B. Medical conditions currently under treatmentYes_____No_____
C. Pre-existing injury currently under treatment? Yes_____No_____
D. Fractures or other disability type injuries? Yes_____No_____
E. Allergy? Yes_____No_____
F. Mental disorder or convulsions? Yes_____No_____
G. Known past illness of more than one week’s duration? Yes_____No_____
H. Contact lenses or glasses? Yes_____No_____
EXPLAIN ABOVE QUESTIONS ANSWERED “YES”
I,_____________________________________________(parent or guardian’s signature) hereby agree to save, ademnify and keep harmless, the Blue Valley School District and Rick Attig’s Camps from all liability, claims, judgements, or demands for damage incurred while above camper is attending one of Rick Attig’s Pole Vault Camps. Please fill out the application completely and mail it along with a non-refundable deposit. If the camp is full the deposit will be refunded.
I hereby state that the Pole Vault Camp is not responsible forany pre-existing injury or reoccurrence of any undisclosed pre-existing injury or illness of the above camper prior to the first day the camper registers.I authorize Rick Attig to obtain medical assistance for my child if needed and release my child to attention as required and deemed necessary by a physician.
Signature of Parent or Guardian
PHYSICIAN’S STATEMENT (or a copy of school physical
I hereby certify that I have examined _________________________and found him/her physically fit to attend and participate in the Pole Vault Camp, and I know of no impairments which wouldlimit his/her participation in all activities in the camp.
Date of last tetus immunization_____________
Elite Pole Vault Camp
Gold Medal Pole Vault Camp
ATP + Gold Medal Camp