Jump Camp Application

Please note that all fields followed by an asterisk must be filled in.

I want to attend (check one)*

	High Jump Camp
	Long & Triple Jump Camp
	Both

First Name*

Last Name*

E-Mail Address*

Street Address*

City*

State/Prov*

Zip/Postal Code*

Home Phone*

Business Phone

Cell*

Sex*

Age*

Grade in fall 2013*

T-Shirt Size*

	Small
	Medium
	Large
	X-Large

Please enter the word that you see below.

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 Airtime Jump Camps and mail to:

Airtime Athletics

c/o Rick Attig

10104 Sunset Dr.

Lenexa, KS 66220

MEDICAL HISTORY (to be completed by the parent)

Is there a known history of:

A. Birth deformities? Yes_____No_____

B. Medical conditions currently under treatment Yes_____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 Airtime Jump 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 Airtime Jump Camp is not responsible for any 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 jump camp, and I know of no impairments which would limit his/her participation in all activities in the camp.

Comments_______________________________________________________

_______________________________________________________________

Date of last tetus immunization_____________

Date examined_______________________

Physician’s signature______________________________________

Address_____________________________________________________

Phone_________________________

High Jump Camp
Airtime Jump Camps