VOLLEYBALL CAMP

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					             Insurance Information
In consideration of the acceptance of this application for
the WHITWORTH VOLLEYBALL SKILLS CAMP, I am aware of
and understand the potential dangers of participating in
contact sport activities. I understand that catastrophic injury
or accident can occur through participation in volleyball,
                                                                                                2010 Northwest Conference Champs!
and I freely and voluntarily assume all such risks and consent
to my daughter’s participation in the Whitworth Volleyball


                                                                                                                      AMP
Skills Camp.


                                                                                                                 LL C
I, intending to be legally bound hereby for myself and my


                                                                                                     EYBA
heirs, executors and administrators, waive and release any



                                                                                                VOLL
and all rights and claims which I may have now or in the
future against Whitworth and its representatives, employees,
respective agents, and/or assignees, for all damages which
may be sustained and suffered in connection with my or
my daughter’s association with any portion of this camp or
related activities, and which may arise out of my or my child’s
traveling to or returning from camp. I know of no medical
or physical problems that may affect my child’s ability to
participate safely in this camp.
I hereby give my consent to the camp staff to attend to any
health problems or injury my daughter may sustain while
attending this camp. Further, I give my consent for medical
treatment and permission to the attending physician to
hospitalize my child, to secure proper treatment, and to order
injections, anesthesia or surgery. I accept full responsibility for
the cost of any medical or other charges in connection with
my child’s attendance at camp.
I certify that my/my child’s active health insurance policy
number and insurance company name are:
_____________________________________________

BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ
THIS WAIVER AND RELEASE FORM AND THAT I UNDERSTAND
                                                                      300 West Hawthorne Road




ALL OF ITS TERMS. I SIGN THIS RELEASE VOLUNTARILY AND
WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.
                                                                      Spokane, WA 99251




_____________________________________________
Parent or guardian name (please print)

_____________________________________________
Signature

_____________________________________________
Date


                                                                                                               17   , 18
                                                                                                      Aug. 16,
                                                                                                                                      Registration
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                                                                                                               First name

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                                                                                                               Last name

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                                                                                                               Home address

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                                                                                                               City/State/ZIP

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                                                                                                               Home phone

                                                Camp Description                                               ______________________________________________________
                                                Get prepared now for your junior high or high                  E-mail
                                                school tryout! This camp will be a comprehensive
                                                                                                               ______________________________________________________
                                                review of all necessary skills for the sport of volleyball.    Date of birth                       Graduation year
                                                Work on your repetitions in the areas of passing,
                                                movement training, defense, attacking, setting, blocking       ______________________________________________________
                                                                                                               Position played                     School
Registration opens May 10 and closes Aug. 13.   and serving. This camp is a great way to get back in the
                                                gym and prepare yourself for tryouts.                          Adult T-shirt size (circle one):   S   M   L   XL
Register early, as camp will fill quickly!
Camp dates: Aug. 16, 17, 18
                                                Coaches                                                        ______________________________________________________
                                                                     The author of one of the greatest         Emergency contact No. 1: name and relationship

Camp times: 6:30-9:30 p.m.                                           turnaround stories in Whitworth           ______________________________________________________
                                                                     athletics history, Steve Rupe is          Phone number
Location: Whitworth University Fieldhouse                            entering his 13th season as head
                                                                     coach of the Pirate volleyball team.      ______________________________________________________
Ages: Entering grades 7-12                                                                                     Emergency contact No. 2: name and relationship
                                                                     Rupe has been named the Northwest
Cost: $130                                                           Conference Coach of the Year three        ______________________________________________________
                                                                                                               Phone number
                                                times (2001, 2002, 2010), and was named the AVCA
Registration link:
                                                West Region Coach of the Year in 2005. Over his 12             ______________________________________________________
www.whitworth.edu/volleyballcamp                seasons as the coach of the Pirates, he has become the
                                                                                                               Insurance company

                                                second-winningest coach in university history, with            ______________________________________________________
                                                a record of 184-130. Under his direction, the Pirates          Policy number
                                                have won four NWC titles and have advanced to the
                                                                                                               ______________________________________________________
                                                NCAA Division III tournament four times (2001, 2002,           Address
                                                2005 and 2010). The team had been nationally ranked
                                                six of the last 10 seasons, with the highest ranking           ______________________________________________________
                                                                                                               City/State/ZIP
                                                (No. 6) coming in 2001. In 2010, the Pirates finished
                                                the year with an NWC title, a second-round appearance          ______________________________________________________
                                                in the NCAA tournament, and a final national ranking of        Phone
                                                No. 24. Whitworth volleyball also led the nation in Div. III            Please send registration and payment to:
                                                attendance in 2001 and 2005. The camp staff will be                                   Steve Rupe
                                                made up of Rupe’s assistant coaches and current and                        Whitworth Volleyball Camp 2011
                                                former players.                                                                 300 W. Hawthorne Road
Kaimi Rocha, All-American                                                                                                         Spokane, WA 99251

				
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posted:11/5/2011
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