Registration Form

Address _______________________________________

City, State and Zip Code _________________________________________

School ________________________________________

Home Phone ___________________________________

Age _______

T-Shirt Size __________________

Personal best in the pole vault ________________

Emergency Contact Name __________________________________________ Phone ______________________

Family Doctor ___________________________________________________ Phone ______________________

Health Insurance Company ________________________________________________

Any medical Conditions ________________________________________________________________________

Please check practice dates:

June 21-22

June 23-24

June 25-26

June 28-29

June 30-July 1

By Signing the line below, I hereby authorize the staff of the Helena Pole Vault Clinic the right to consent any medical treatment needed for my son/daughter. I hereby state that I or my son/daughter have had and passed a physical examination in the past year and that I am sure that he/she is in good health in which to compete in the rigors of the events in the camp. I hereby assume all responsibilities for myself or my son/daughter and hereby hold FREE the Helena Pole Vault Clinic harmless for all accident, injury, illness, death, or damage occurring by reasons of the clinic.

Signature of Athlete ________________________________________________ Date _________________

Signature of Parent or Guardian (If athlete is a minor) _________________________________________ Date _____________

 Mail with payment to Doug LeBrun, Pole Vault Practice Center, 1255 Ryans Lane, Helena MT 59602