Pole Vault Clinic Registration

I. Personal Information

Participants Name *

Address *

City *

State *

Zip Code *

Home Telephone # *

Mobile #

Email Address *

Sex *

Male

Female

Grade (as of 11.2010) *

Age *

How did you learn about this clinic? *

Dyestat

MileSplit

Harrier

Other

II. Emergency Contact Information

Parent/ Guardian(s) *

Telephone # *

Mobile # *

III. Registration Fee and Deadline

Registration deadline is November 11th or until there is no available space. Due to the

popularity of the clinic and a limited number of spaces available, get your application in

early to ensure acceptance.

Please return this application (& Waiver & Release) along with a $100 non-refundable

fee (payable to Pole Vault Carolina) or via on-line registration by Nov 11th.

Registration deadline is November 11th or until there is no available space. Due to the popularity of the clinic and a limited number of spaces available, get your application in early to ensure acceptance.

Please submit this registration form then pay your $100 non-refundable fee via PayPal from our website at www.polevaultcarolina.com.

IV. Waiver and Release

In consideration of my application being accepted, I, intending to be legally bound, do

hereby release and forever discharge any and all rights and claims for damages, which I

may have or which may hereafter accrue to me against Jose R. San Miguel, Jim Bemiller,

Cardinal Gibbons High School, or its or their respective officers, agents, coaches for any

or all damages which may be sustained or suffered by me in connection with my

participation in, and/or rising out of my traveling to or returning from said Clinic; or the

campus of Cardinal Gibbons High School. Applicant further attests and verifies that he or

she is physically fit and has sufficiently trained to participate in all events. Further,

applicant attests that his or her health insurance will cover any medical and hospital

expenses that he or she incurs; and that he or she has passed a sports participation

medical exam within the past year.

In consideration of my application being accepted, I, intending to be legally bound, do hereby release and forever discharge any and all rights and claims for damages, which I may have or which may hereafter accrue to me against Jose R. San Miguel, Jim Bemiller, Cardinal Gibbons High School, or its or their respective officers, agents, coaches for any or all damages which may be sustained or suffered by me in connection with my

participation in, and/or rising out of my traveling to or returning from said Clinic; or the campus of Cardinal Gibbons High School. Applicant further attests and verifies that he or she is physically fit and has sufficiently trained to participate in all events. Further, applicant attests that his or her health insurance will cover any medical and hospital expenses that he or she incurs; and that he or she has passed a sports participation

medical exam within the past year.

Pole Vault Carolina Clinic reserves the right without notice to modify, change or revoke the arrangements, regulations, curriculum and instructional materials used in its programs. Pole Vault Carolina reserves the right to refuse admission to any student at any time should Pole Vault Carolina determine such action is in the interests of the school or student. Pole Vault Carolina assumes no liability for personal injury or for the loss or

damage of personal property.

Parent/ Guardian Name *

By checking this box you agree to the terms explained above by Pole Vault Carolina and are granting your digital signature for the waiver and release. *

I Agree

V. Health Insurance/ Medical History

This form must be completed and signed by the participant’s legal guardian. The information we ask you to

provide is necessary in the event your child needs medical treatment while camp is in session. This form

will be returned to you if it is incomplete. Please type or print in black ink.

This form must be completed and signed by the participant’s legal guardian. The information we ask you to

provide is necessary in the event your child needs medical treatment while camp is in session.

PARTICIPANT INFORMATION

Participant Name *

Sex *

Male

Female

INSURANCE POLICY INFORMATION

Backup Contact (relative or friend): Name *

Relation *

Daytime Phone *

Eve Phone *

The above-named child is covered by health insurance *

Yes

Policy Honder (PH) Name *

DOB *

Address *

City *

State *

Zip *

PH Employer *

Occupation *

Employer Address *

Plan # *

Insurance Company *

Policy # *

MEDICAL HISTORY

DOES THE PARTICIPANT CURRENTLY HAVE ANY OF THE FOLLOWING? (please describe)

MEDICAL HISTORY

DOES THE PARTICIPANT CURRENTLY HAVE ANY OF THE FOLLOWING? (please describe)

Drug allergies *

Food allergies *

Allergies to insect bites *

Special dietary needs *

Asthma *

Frequent headaches *

Dizziness or seizures *

List other health problems *

List limitations of activities *

List medications the camper is taking *

(Please note: Our staff cannot administer any medications, prescription or non-prescription to campers.

This includes over-the-counter medicines like Advil or Tylenol for minor headaches or pains. If the camper

will need to take medications while attending our program, s/he must bring the medication to camp and

assume responsibility for taking it as needed or indicated.)

(Please note: Our staff cannot administer any medications, prescription or non-prescription to campers.

This includes over-the-counter medicines like Advil or Tylenol for minor headaches or pains. If the camper

will need to take medications while attending our program, s/he must bring the medication to camp and

assume responsibility for taking it as needed or indicated.)

Will your son/daughter require any specific treatment for a medical/emotional condition while participating

in our program?

Will your son/daughter require any specific treatment for a medical/emotional condition while participating in our program?

Yes

Initial here to provide your digital signature acknowledging the validity of the insurance information *

VI. Medical Treatment Consent

I, the legal guardian of the above-named camper, authorize the Pole Vault Carolina staff

to seek medical treatment for the participant as they see necessary at a nearby facility. I

consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital

care subsequently deemed necessary by a licensed health care provider during the

participant’s session. I understand that this authorization is given in advance of any

specific diagnosis, treatment or hospital care, and that it is given to provide the program

staff authority to seek medical treatment, and to provide a licensed health care provider

the authority to administer this treatment as s/he judges necessary to the above-named

child. I accept responsibility for payment of all services rendered; I authorize any medical

facility which renders services to release medical information necessary for the

processing of insurance claims; and I authorize the payment of insurance claims directly

to the medical facility. I understand that whenever possible, the Program staff will make a

good faith effort to contact me or the above-named person(s) before seeking treatment. If

this is not possible, I understand that the Program staff will notify me or my designee as

soon a possible of any and all diagnoses and treatments.

I, the legal guardian of the above-named camper, authorize the Pole Vault Carolina staff to seek medical treatment for the participant as they see necessary at a nearby facility. I consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care subsequently deemed necessary by a licensed health care provider during the participant’s session. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care, and that it is given to provide the program staff authority to seek medical treatment, and to provide a licensed health care provider the authority to administer this treatment as s/he judges necessary to the above-named child. I accept responsibility for payment of all services rendered; I authorize any medical facility which renders services to release medical information necessary for the processing of insurance claims; and I authorize the payment of insurance claims directly to the medical facility. I understand that whenever possible, the Program staff will make a good faith effort to contact me or the above-named person(s) before seeking treatment. If this is not possible, I understand that the Program staff will notify me or my designee as soon a possible of any and all diagnoses and treatments.

Initial here to agree to the above statement *

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