*****************
2013 CAMP APPLICATION
*****************

PRINT & RETURN with Check Payable to:
Logger Volleyball Camp
University of Puget Sound Athletics
1500 N. Warner CMB 1044,
Tacoma WA 98416-1044

NAME ________________________________________________________

STREET ______________________________________________________

CITY/ST/ZIP ____________________________________________________

HS/CLUB NAME ________________________________________________


I will attend the following camp(s): (Space Limited!)

_____ $149 SETTER/HITTER ACADEMY Aug. 5-8, 1:30-4:30pm, gr. 8-12 only
(Check One: __ Setter __ Outside __ Middle )
_____ $109 BASIC SKILLS Camp, Aug. 5-8, 9am-Noon, gr. 6-9
_____ $109 COMPETITION CAMP, Aug. 5-8, 5:30-8:00pm, gr. 8-12 only
_____ $49 COMPLETE PLAYER TUNE-UP Aug. 9, 9:00am-4:30pm, gr. 8-12 only
_____ $69 LIBERO INTENSIVE Aug. 10, 9:00am-4:30pm, gr. 8-12 only


AGE _____ HEIGHT _____ GRADE (next Fall) _____

HOME PHONE (______)__________________________

EMERGENCY DAY PHONE (PARENT):
(_____)_______________________________________

EMAIL
_____________________________________________

Adult T-Shirt size (circle one): S M L XL


REQUIRED MEDICAL RELEASE FOR SUMMER CAMPS

I, the undersigned parent/guardian of ____________________________________, a minor, do hereby authorize the directors, staff and medical staff of the Logger Camp or their designee to act for me according to their best judgment in any emergency requiring medical attention, and to select hospital facilities and/or a physician of their choice and authorize treatment of the above named camper on an emergency basis in the event that such treatment becomes necessary as a result of participation in the Logger Camp.

I will be responsible for any medical or other charges in connection with her/his participation at camp. I understand the above named camper will be involved in strenuous physical activity. I hereby grant permission for the above named camper to participate in all camp activities. I have no knowledge of any physical impairment that would be affected by the above named campers participation in the camp program.

I understand participation can result in injury, including, but not limited to catastrophic injury, death, paralysis, injury to virtually all bones, joints, ligaments, muscles, and tendons and serious injury or impairment to other aspects of the body. I hereby assume all risks associated with participation and agree to unconditionally release the University of Puget Sound, its coaches, staff, athletic trainers, and their employees from any and all liability. If a serious injury or medical condition should occur in conjunction with participation in a Logger Summer Camp, the medical and/or coaching staffs will attempt to contact a parent or guardian. In the event immediate contact cannot be established, the following statements are provided for your authorization/permission. If you do not wish to provide this authorization, please attach a separate piece of paper explaining what exact procedure you wish to be followed.

I/We authorize the camp staff at the University of Puget Sound to render any first aide or preventative, rehabilitative or emergency treatment deemed reasonably necessary to the health and well-being of the above named camper.

I/We additionally grant permission for hospitalization treatment at an accredited facility, when it is necessary to protect the health and well-being of the above named camper, in the judgment of the camp staff.

Please note any medical conditions, medications take, or allergies:

___________________________________________________________________________

Parents signature:____________________________________________

Medical Insurance Company Name and Phone Number:

_______________________________________________________ (____)____-_________

Name Of Policy Holder:__________________________ Policy # _____________________

Policy Holder SSN _____-____-________ Policy Holder Date of Birth ___/___/____



Emergency Contact Information

Emergency Contact:____________________________

Emergency Phone

(Work)_____________________

(Home)_____________________

(Cell)_____________________

Secondary Emergency Contact: __________________________________

Secondary Contact Phone:_________________________