This form must be completed and submitted with payment before
you will be allowed to participate.
Registration Form:
Name:
__________________________________________________________
Male:
_____ Female: _____ T-Shirt Size:
S M L
XL
Email address:
__________________________________________________________
Home Address:
__________________________________________________________
__________________________________________________________
City/State:
__________________________________________________________
Zip:
__________________
Parents’ Name:
__________________________________________________________
Home
Phone:
__________________________________________________________
Athlete’s Cell
Phone:
__________________________________________________________
Emergency
Phone and Contact Person:
__________________________________________________________
Age:
_______ Birth Date:
__________________________
HS Graduation Date:
__________________
School Name:
__________________________________________________________________________
School
Coach:
_________________________________________________________________________
What
is your PR (personal record): ______________
Informed Consent and
Release
I hereby grant permission for myself / child to attend Pure Sky Vault
Club. I verify that I / my child has had a physical exam in the past year and is
capable to participate in the activities related to pole vaulting. I agree to
indemnify, hold harmless, and defend all coaches and staff of Pure Sky
Athletics, USA Track and Field, Pure Sky Athletics, their agents, employees and
sponsors from any and all liability for injury to myself and/or my child. I
understand that track and field, and in particular pole vaulting and many of its
related activities are potentially dangerous and could pose risk of injury.
Should medical attention be necessary, I hereby authorize any physician or
trainer selected by the club personnel to conduct medical or surgical
procedures. In addition, I hereby grant permission for Pure Sky Athletics to use
any photographs or videotape of club related activities for the purpose of
advertising or educational materials development. I HAVE READ AND UNDERSTOOD,
AND AGREE WITH THE INFORMED CONSENT AND RELEASE OUTLINED AS IT RELATES TO
MYSELF/SON/DAUGHTER.
Participant Signature:
__________________________________________________________________
Parent / Guardian Signature:
______________________________________________________________