COMPLETE THE CAMP APPLICATION

Pole Vault Camp Application 2012
I want to attend (check one)*Winter Pole Vault Camp (Dec 28-30)
Elite Pole Vault Camp (June 17-21)
ATP + Gold Medal Camp (July 5-12)
Gold Medal Camp (July 8-12)
First Name*
Last Name*
E-mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Home Phone*
Business Phone
Cell*
Sex*
Age*
Grade (fall of 2013)*
T-Shirt size*Small
Medium
Large
X-Large
Medical Insurance Company and Policy number*

Please enter the word that you see below.

  



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:

PVU

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

________________________________________________________________

Date_________________

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.

Comments_______________________________________________________

_______________________________________________________________

Date of last tetus immunization_____________

Date examined_______________________

Physician’s signature______________________________________

Address_____________________________________________________

Phone_________________________

Elite Pole Vault Camp
Gold Medal Pole Vault Camp
ATP + Gold Medal Camp