Medical History

(to be completed by the parent and mailed in with deposit)

Print the forms below and send in with your camp deposit.

 

Make cashier's check or money order for non-refundable deposit or payment in full payable to Pole Vault U and mail to:

 

Pole Vault University

c/o Rick Attig

1291 N. 1083 Road

Lawrence, KS 66049

 

Athlete's name:________________________________________Camp attending:____________________________________

 

MEDICAL HISTORY:

 

Is there a known history of:

 

A.    Birth deformities? Yes_____No_____

 

B.    Medical conditions currently under treatment Yes_____No_____

 

C.    Pre-existing injury currently under treatment? Yes_____No_____

 

D.    Fractures or other disability type injuries? Yes_____No_____

 

E.    Allergy? Yes_____No_____

 

F.    Mental disorder or convulsions? Yes_____No_____

 

G.    Known past illness of more than one week’s duration? Yes_____No_____

 

H.    Contact lenses or glasses? Yes_____No_____

 

EXPLAIN ABOVE QUESTIONS ANSWERED “YES”

 

____________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________ 

 

I,_____________________________________________(parent or guardian’s signature) hereby agree to save, ademnify and keep harmless, Washburn Athletics, Washburn University and Rick Attig’s Camps from all liability, claims, judgements, or demands for damage incurred while above camper is attending one of Rick Attig’s Camps. Please fill out the application completely and mail it along with a non-refundable deposit. If the camp is full the deposit will be refunded.

 

I hereby state that Rick Attig's Camp is not responsible for any pre-existing injury or reoccurrence of any undisclosed pre-existing injury or illness of the above camper prior to the first day the camper registers. I authorize Rick Attig to obtain medical assistance for my child if needed and release my child to attention as required and deemed necessary by a physician.

 

Signature of Parent or Guardian

 

________________________________________________________________

 

MEDICAL INSURANCE COMPANY AND POLICY NUMBER________________________________________________________

 

Date_________________

 

PHYSICIAN’S STATEMENT (or a copy of school physical)

 

I hereby certify that I have examined _________________________ and found him/her physically fit to attend and participate in the jump camp, and I know of no impairments which would limit his/her participation in all activities in the camp.

 

Comments_______________________________________________________

 

_______________________________________________________________

 

Date of last tetus immunization_____________

 

Date examined_______________________

 

Physician’s signature______________________________________

 

Address_____________________________________________________

 

Phone_________________________ 

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