Pole Vault Camp Oct. 14, 21, 28; Nov. 4, 11 Grades 9-12

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1 TRACK & FIELD Patrick Georgia October-November Pole Vault Camp Oct. 14, 21, 28; Nov. 4, 11 Grades 9-12 The Spring Season Is Fast Approaching To help you get a jump on the competition, St. Norbert is pleased to invite you to our pole vault camp. Working with some of the best coaches in the area and SNC s student-athletes will give you the winning edge this upcoming season. Don t delay; register now! Space is limited to just 12 vaulters so that each athlete receives the highest level of personal attention. We look forward to working with you! Five Sessions Sundays, Oct. 14, 21, 28; Nov. 4, p.m. Patrick Georgia, a St. Norbert College alumnus, has been a pole vault guru since competing in the event during a dominant collegiate career. Now in his 14th season coaching at SNC, his athletes hold three of the four school pole vault records. Taylor Pasterski Taylor Pasterski 15 is in his second year coaching the vaulters, and also assists with strength and conditioning. As a student, he competed as a member of the St. Norbert College track and field team and specialized as a long sprinter. During his career, he was a four-time national qualifier and three-time All-American. In order to receive the maximum benefit, athletes should plan on attending all five sessions. Athletes must bring their own pole (and a helmet, if desired).

2 October-November Pole Vault Camp REGISTRATION Boys and girls entering grades 9-12 are invited to join the St. Norbert College coaching staff for five days of skills development! Please print clearly. Last Name, First Address City State ZIP Home Phone Cell Phone High School Graduation Year Send completed form and check payable to St. Norbert College Track & Field to: St. Norbert College c/o Track & Field 100 Grant St. De Pere, WI COST: $40 per session or $165 for all 5 sessions ADDITIONAL INFORMATION: Contact Elizabeth Krug at elizabeth.krug@snc.edu or Personal Bests Please complete the required insurance form found on the next pages and return it with this registration.

3 I, the undersigned parent/guardian, request voluntary participation for my child (furthermore know to as minor and/or minor s ) to participate in the St. Norbert College Track & Field Pole Vault Camp to be held on the St. Norbert Campus on/from which may consist of, but is not limited to, running, jumping, and vaulting hereinafter referred to as the The Activity. CONSENT: I consent to minor s participation in The Activity and acknowledge that I fully understand minor s participation may involve risk of serious injury or death, including losses which may result not only from minor s own actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the event or activity is being conducted, and/or the rules of the of activity. I understand that if I have any risk concerns, I should discuss the risks associated with my participation with the activity coordinators and event staff, before I sign this document and before the activity begins. CONCUSSION: I, the undersigned, have read the Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors along with the importance of reporting a suspected concussion that occurs during the Activity. I understand that Camper must be removed from practice/play if a concussion is suspected. I understand that it is my responsibility to seek medical treatment if a concussion is suspected. I understand that anyone suspected of a concussion cannot return to practice/play until providing the camp written clearance from an appropriate health care provider. I understand the possible consequences of a camper suspected of a concussion returning to practice/play too soon ASSUMPTION OF RISKS: I acknowledge that I am aware there are risks associated with or related to participation in the activity. Such participation in the activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Although the risk of injury is low during the activity, there are still risks. These risks, such as but not limited to, range from (1) minor injuries such as slips, trips, falls, scratches, cuts, bruises and sprains, burns, insect bites, food poisoning, (2) major injuries such as joint or back injuries, fractures, heat exhaustion/stroke, and concussions, (3) life-altering injuries including head trauma, heart attacks, drowning, assaults/molestations, animal attacks, catastrophic, major burns, paralysis, to (4) death. I freely accept and fully assume all such risks, dangers and hazards and the possibility of personal injury, death, permanent disability, property damage or loss resulting thereof. Knowing and understanding the risks involved with participation in the activity, I hereby voluntarily and willingly assume responsibility for all risks and dangers associated with minor s participation in the activity. Notwithstanding anything herein to the contrary, I acknowledge that the foregoing assumptions of risks does not include any injury arising because of any intentional, willful, or grossly negligent act of any other party. CERTIFICATION OF HEALTH STATUS AND INSURANCE COVERAGE: I certify that minor is in good health and has no physical condition that would prevent participation in this activity. Furthermore, I attest that minor is covered under a current and valid health insurance plan and agree to use such personal medical insurance as a primary medical coverage payment if accident or injury occurs. I consent to emergency medical treatment in the event such care is required, and I acknowledge that I am responsible for related costs. RELEASE FOR MEDIA/PRESS COVERAGE: I agree that photographs, pictures, slides, movies, video, or other media coverage of minor may be taken in connection with minor s participation in the activity without compensation from St. Norbert College, the Premonstratensian Fathers, their officers, employees, and agents of each of them and consent to the use of photographs, pictures, slides, movies, videos, or other media coverage for any legal purpose.

4 Page 2 TRANSPORTATION: Transportation for the Activity may or may not be arranged by St. Norbert College, I accept the risks inherent in any such arrangements and/or the risk associated with travel. I understand that the College cannot be responsible for assuring the safety and reliability of public or private transportation for The Activity and non-sponsored activities and travel that I choose to participate in before, during or after the College sponsored function, and therefore I accept the risks and responsibilities associated with such travel arrangements. WAIVER/INDEMNITY In consideration of minor s participation in the activity, I hereby waive all claims or causes of action against St. Norbert College, Inc, the Premonstratensian, their Officers, Directors, employees and agents, arising out of minor s participation in the activity and hereby release, hold harmless, and discharge St. Norbert College, Inc., the Premonstratensian Fathers, their officers, directors, employees and agents of each of them from all liability in connection therewith except such loss or damage which was caused of any intentional, willful, or grossly negligent act of any other party or that of St. Norbert College Inc., the Premonstratensian Fathers, their officers, employees, representatives and volunteers, and the officers, directors, employees and agents of each of them. I agree I am financially responsible for any losses resulting from minor s actions and will indemnify St. Norbert College, Inc., the Premonstratensian Fathers, their officers, directors, employees and agents of each of them, for any loss or damage caused by minor during this activity. SEVERABILITY: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Wisconsin and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. ACKNOWLEDGEMENT OF UNDERSTANDING: I have read this release and hold harmless agreement, and understand the terms used in it and their legal significance. This waiver and release is freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability as relates to The Activity to the greatest extent allowed by law. ACKNOWLEDGEMENT OF UNDERSTANDING: I have read this release and hold harmless agreement, and understand the terms used in it and their legal significance. This waiver and release is freely and voluntarily given with the understanding that right to legal recourse against St. Norbert College, Inc., the Premonstratensian Fathers, and the officers, directors, employees and agents of each of them is knowingly given up in return for allowing minor s participation in the activity. My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.

5 Page 3 Please utilize the space below to provide any medical/prescription information that you request be released to emergency medical providers. IN WITNESS WHEREOF, I have executed this affirmation and release at De Pere, WI on the below: Emergency contact name (print) Participant s signature Parent s signature (required) Relationship to the participant List Physician Name and Phone Number below: List known allergies and any other medical/prescription information you request be released to emergency medical providers. Participant s Name (print) Address City/State Zip WITNESS (must be at least 18 years old) Signature