Camp Registration Form (Page 2 of 2) in pdf

CAMPSTAFF

GENERALINFO

PARENTAL AUTHORIZATION

All information on this form must be completed in order to guarantee a

place in the camp.

REGISTRATION

Purdue University Medical Authorization for Treatment of a Minor (persons under 18

Registration will be from 12-1pm on Thursday, July

years) Pursuant to Indiana Code Paragraph 16-36-1-6, I request and authorize the

Purdue University Student Health Center, Purdue University Ambulance Service, IU

16.

15. Campers may choose the residential or commuter

Health Arnett, and St. Elizabeth Hospital medical personnel, agents and employees

option. Residential camp includes room and meals.

to provide all reasonably necessary medical care advisable for the health of my child,

Commuter campers will attend from 7:30 a.m. to 4 p.m.

including but not limited to medical transport, hospital tests, such as pathology,

radiology, anesthesia, evaluation and treatment by physicians, including surgery, and

and will receive breakfast and dinner. This camp is for

prescription drugs. I acknowledge that no representations warranties, or guarantees

boys and girls, entering grades 6-12. Campers are

can be made with respect to any medical care or treatment provided. I also understand

ROLANDO

NORBERT

ANGELA

expected to attend planned sessions and to comply with

that, as a result of my child’s participation in this program, it will be necessary for

GREENE

ELLIOTT

GOODMAN

the rules and regulations of Boiler Track & Field and

supervisor’s, coaches, residence hall personnel, and others involved with the program

SPRINTS AND HURDLES

to have access to relevant medical information pertaining to my child, and I authorize

SPRINTS AND RELAYS

Cross Country Camp. Registration can be done online

SPRINTS

the use and disclosure of my child’s medical information to promote a safe and healthy

experience for my child. Further, I hereby grant permission for my child:

TEAM DISCOUNT

_________________________________________________________

Minor’s Name

Date

A team discount is available for five or more participants from

one team or school. Group must register together to receive the

To attend the 2015 Boiler Track & Field and Cross Country Camp by

discount. Each participant must complete the camper registration

signing below, a signature from one or both parents/legal guardians and a

form and the physician’s approval form. This discount will only be

KEITH

CHRIS

witness signature is required.

JEFF

applied to the residential registration option.

BRIDE

HUFFINS

KENT

_________________________________________________________

VERTICAL AND

THROWS

DISTANCE

CAMP REFUND POLICY

Signature of Parent/Legal Guardian (required)

HORIZONTAL

JUMPS

All refunds are subject to a $100 processing fee. Refunds will be

_________________________________________________________

granted if the request is received in writing no later than June

Signature of Parent/Legal Guardian/Witness (required)

15, 2015. No refunds will be granted after that date.

COLLEGIATE ATHLETES WILL ALSO BE ASSISTING.

PHYSICIAN APPROVAL

EQUIPMENT

Each camper should wear comfortable work-out clothing (t-shirt,

I have examined: ___________________________________________

and found him/her to be healthy to compete in track & field/cross country

shorts, etc.) for each camp session. Additionally, campers should

and general recreational activities of his/her choosing during the 2015 Boiler

bring their own workout gear, including event specific shoes/spikes,

Track & Field and Cross Country Camp.

and implements (poles, shots, discuses, etc.) if they have them. Mark

all individual equipment so it can be identified easily.

Medical Condition(s): ________________________________________

CAMPFEATURES

HOUSING AND MEALS

Current Medication(s): _______________________________________

Campers, counselors, and staff members will be housed in Cary

Allergies: _________________________________________________

Quadrangle Residence Hall on the Purdue West Lafayette campus.

The camp will reside in an air-conditioned building. Rooms are for

Date of Last Tetanus Shot: ____________________________________

(If date is not supplied, child may be required to obtain a tetanus shot if injured.)

•

INSTRUCTION BY PURDUE COACHING STAFF IN YOUR

double occupancy only; linens are provided. Campers will be

assigned a roommate unless one is indicated on the registration

CHOSEN EVENT AREA(S)

Physician’s Signature: ________________________________________

form. Roommate requests must be mutual, and registration forms

•

WARM-UP EXERCISES

Phone: ___________________________________________________

must be returned together. Meals will be provided.

•

DRILLS

•

TECHNICAL SESSIONS

EMERGENCY CONTACT

•

NUTRITIONAL INFORMATION

MEDICAL CARE AND INSURANCE

First Contact Name: _________________________________________

•

STRENGTH SESSIONS

Athletic Trainers are on duty during camp hours. They will provide

Relationship to Participant: ____________________________________

•

CONSTANT FEEDBACK

immediate medial attention to anyone who is injured or becomes ill.

•

T-SHIRTS PROVIDED

Day/Night Phone: ___________________________________________

They will also attend to general athletic training needs. The major

•

AIR-CONDITIONED HOUSING

hospitals in the area are all located within fifteen minutes of camp

Second Contact Name: _______________________________________

•

LIVE-IN CAMP COUNSELORS

facilities. A licensed physician must sign the registration form (a

Relationship to Participant: ____________________________________

•

RANKIN TRACK & FIELD COMPLEX

school medical form signed no less than 12 months prior to camp is

also acceptable). No medical forms will be returned. All registrations

Day/Night Phone: ___________________________________________

•

BOILERMAKER CROSS COUNTRY COURSE

must include this in order to hold your space.

•

TEAM DISCOUNT*

Purdue University is an equal access/equal opportunity university

Camp Registration Form Page 2

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