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Pole Vaulting Application Form |
Gold Country Pole Vaulters“Going for the Gold!” (A Division of CTM Inc)
I hereby grant permission for myself/my child to attend the Gold Country Pole Vaulting Club (a division of Christian Team Ministries Inc) pole vaulting lessons and instruction at William Jessup University, 333 Sunset Blvd, in Rocklin, CA; and instruction and competitions at other venues as determined by future practice and meet schedules.
I verify that I/my child have had a physical exam in the past year and that I/my Child am/is capable to participate in the activities related to pole vaulting. I agree to indemnify, hold harmless, and defend Nick Vogt, GCPV Club coaches, William Jessup University, and Christian Team Ministries Inc, their agents, employees and sponsors from any and all liability for injury to my child or myself, as well as any damage caused by my child or myself.
I understand that track and field events and in particular pole vaulting is a dangerous activity from which injury or death could result. I hereby authorize any physician or trainer selected by club personnel to conduct medical or surgical procedures necessary.
In addition, I grant Gold Country Pole Vaulting to use any videos or photographs of myself /my child in lesson and competition related activities for the purpose of advertising or coaching/educational productions.
Insurance Information and Parent Signature is Required Prior to Participation in Lessons and Competition.
MEDICAL INSURANCE COMPANY: ______________________________________
POLICY # : ____________________________________________________________
PLEASE PRINT NAME: _________________________________________________
PARTICIPANT SIGNATURE: ____________________________________________
PARENT/GUARDIAN SIGNATURE: (if participant is under 18)
_________________________________________________________
DATE: __________________
EMERGENCY PHONE: (_____) ________________
ADDRESS: ________________________________
CITY__________________ ST____ZIP__________
SCHOOL OR COLLEGE _____________________
USATF CLUB _____________________________
USATF MEMBERSHIP # ____________________ (Expiration Year)
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Return this form to: Coach Nick Vogt Gold Country Pole Vaulting1025 Grange Road Meadow Vista, CA 95722 (530) 878-0697
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