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					                                                  2010 NDSU POLE VAULT WINTER CLINICS
POLE VAULT CLINIC SESSIONS                                                          Consent for Medical Treatment Consent
These pole vault clinics are designed for                                           to Participate
beginners or for experienced vaulters.                                              Validation of Insurance
The clinics are great opportunities for                                                           I/We undersigned, hereby authorize any first aid,
vaulters to learn the basics of the pole                                                          medication, medical treatment or surgery deemed
vault and to have experienced eyes watch                                                          necessary in case of emergency for (print full name):
and help correct vaulting technique. Also,                                                        _____________________________________________
vaulters will get a chance to learn circuits                                                      _ a participant in a Bison track & field camp. I/We
                                                                                                  understand that I/we will be responsible for any
that help enhance the specific strength                                                           expenses incurred on his/her behalf in connection with
needed for vaulting and a weight room                                                             such treatment. I/We also authorize the camp appointed
session will help direct athletes into what                                                       physician to execute on my/our behalf any permission
type of strength training is needed to                                                            slips and other appropriate documents and act on my/our
excel as a pole vaulter.                                                                          behalf in I/we are not immediately available to do so.
                                                 North Dakota State University does not           __ Insurance Company
February, 14 2010                                                                                 _____________________________________________
 8:00 a.m. Registration,
                                                 discriminate on the basis of race, color,        __ Contract Numbers
            Bison Sports Arena                 national origin, religion, sex, disability, age,   _____________________________________________
                                                   Vietnam Era Veterans status, sexual            __ Emergency Daytime Phone Number
 8:30 a.m. Introduction                                                                           NO CAMPER WILL BE ADMITTED TO CAMP
 8:45 a.m. Warm-up                                 orientation, marital status, or public         WITHOUT INSURANCE COVERAGE. Injuries are a
 9:00 a.m. Technique work                        assistance status. Direct inquiries to the       part of training camp. It is very important that you are in
10:30 a.m. Break                               Chief Diversity Officer, 205 Old Main, (701)       good shape when you report to camp. The better shape
11:00 a.m. Technique work                                                                         you are in, the less likely you are to sustain an injury. If
                                                                 231-7708.                        you receive a major injury, you will be returned home.
 1:00 p.m. Lunch                                                                                  There are no refunds due to injuries or illness.
 1:30 p.m. Closing session                      WAVER: ASSUMPTION OF RISK RELEASE                 As a condition of enrollment, the following disclaimer
                                               FORM WILL NEED TO BE SIGNED PRIOR TO               of liability must be signed and dated by the camper's
                                                                                                  parent/legal guardian: The camper, in attending the
February, 20 2010
                                                   PARTICIPATION IN ALL CLINICS.                  NDSU Track and Field Camp and in using any camp
                                                                                                  facility, does so at his/her own risk. The University, its
 8:30 a.m. Registration,
                                                                                                  Athletic Department and its staff shall not be liable for
            Bison Sports Arena                                                                    any damage arising from personal injury sustained by
 9:00 a.m. Introduction                        What to Bring:                                     the camper during the camp session and so hereby fully
 9:15 a.m. Warm-up                             Training shoes, spikes                             and forever exonerate and discharge the University, the
 9:30 a.m. Technique work                      Helmet                                             NDSU Track and Field Camp, its staff, its owners,
11:30 a.m. Lunch Break                         Water bottle                                       employees and agents, from any and all claims,
                                               Notebook and pen                                   demands, damages, right of action or cause of action,
            Video Session                                                                         present or future, whether the same be known,
 1:30 p.m. Weight room                         Dress in training clothes and sweats               anticipated, or unanticipated, resulting from or arising
 2:00 p.m. Warm-up                             Pole vault poles (I will have poles available)     out of the camper’s participation in the camp session and
 2:15 p.m. Technique work                                                                         in the use of the facilities.
 4:00 p.m. Closing session                                                                         I certify that to the best of my knowledge, I am in
                                                                                                  good physical condition and have no disease or injury
                                                                                                  that would impair my performance in training or

                                                                                                  __ Camper’s Signature & Date

                                                                                                  __ Parent or Guardian Signature & Date

Please return to:                                 (name)                                          REGISTRATION FORM
Nancy Erickson                                    (address)                                       SIGN UP FOR:                                   Price
BISON SPORTS ARENA                                                                                □ February 14th, 2010                          $40
P.O. BOX 6050                                                                                     □ February 20th, 2010                          $60
FARGO, ND 58108
                                                                                                  □ Both Clinics
For questions contact Stevie Keller               __________________________________________
Phone: 701-793-0374
                                                                                                  *Makes Checks Payable to:
Fax: 701-231-6246                                 Signature                  Date                  NDSU Athletics
Email: stevie.keller@ndsu.edu
                                                  Signature of Parent/Guardian

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