WASHINGTON STATE UNIVERSITY COUGAR FOOTBALL 2017 MINI CAMP

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1 Date: Saturday, July 29 (11AM TO 3PM) WASHINGTON STATE UNIVERSITY COUGAR FOOTBALL 2017 MINI CAMP Eligible Grades: Any and all entering grades 10 th or 11 th or 12 th in the fall of 2017 Location: Washington State University Athletic Facilities, Pullman, Washington Cost: $50 Includes camp instruction and camp t-shirt. This non-contact camp will be an afternoon event in which you will have a chance to see the WSU Football facilities, meet with our coaches, and have the chance to show off your skills with instruction from our coaching staff. You will go through agility drills, followed by more football specific drills, 1 on 1 s and 7 on 7. Deadline: Walkups will be taken on a space available basis after completion of all required forms and parent signatures. Campers must complete all the required forms in this packet including parent signatures before participation. Any missing information will delay acceptance into the camp. We do NOT require proof of a physical. We do require campers have their own medical insurance. An athletic trainer will be on duty throughout the entire event. A doctor is on constant call, and hospital facilities are readily accessible. Equipment: work out attire, tennis shoes, cleats. Outdoor sessions will be on FieldTurf. Check-in begins at 11AM in the Heritage Hall of the new Cougar Football Complex (see enclosed map). Instruction will begin at 12pm, moving outside to Rogers Field/Martin Stadium at approximately 1:30pm. A meal is not provided, so please eat prior to check-in. Water will be available at all times. Parents/family are welcome to watch the outdoor sessions. Instruction on Rogers Field and/or Martin Stadium will begin at approximately 1:30pm. Parking Make sure you are legally parked. Parking is enforced 24 hours a day, every day. Read the signs as you enter the lot and make sure it is available for parking on Saturdays. WSU Football will not be responsible for parking violation costs or appeals. A detailed parking map is included in this packet. Refund Policy The payment for the Mini Camp is non-refundable. Refunds are possible for medical emergencies or unforeseen accidents ONLY. A physician s letter of explanation prior to the first day of camp must accompany any refund requests. All potential refund situations will be evaluated at the end of the camp. Approved refunds will be credited after August 21, Submission of the application indicates acceptance of this policy. Travel to Pullman Please visit the WSU Visitor Center for driving directions BY AIR - the Moscow-Pullman Regional Airport is serviced by Alaska Airlines. Please contact our office 48 hours prior to your arrival to arrange transportation from the Moscow-Pullman Regional Airport. We will NOT be able to provide transportation from the Lewiston (Idaho) Airport or Spokane International Airport. There is a shuttle service available from the Spokane Airport ( ), however please contact the shuttle company before booking any travel into/out of Spokane to make sure they will make your connections. CONTACT: Phone: football.camp@wsu.edu

3 WSU COUGAR FOOTBALL MINI CAMP Saturday, July 29, 2017 Refund Policy The payment for the Mini Camp is non-refundable. Refunds are possible for medical emergencies or unforeseen accidents ONLY. A physician s letter of explanation prior to the first day of camp must accompany any refund requests. All potential refund situations will be evaluated at the end of the camp. Approved refunds will be credited after August 21, 2017 Contact Information: Washington State University 510 Cougar Football Complex P O Box Pullman, WA Phone: Fax: football.camp@wsu.edu Web: NAME OF CAMPER SCHOOL CAMPER ATTENDS Method of Payment: $50 Cash Personal Check # Money Order # Charge Card TOTAL AMOUNT TO CHARGE **************************************** NAME ON CARD (print) CARD NUMBER VISA OR MASTERCARD ONLY Visa starts with 4, Mastercard starts with 5 EXPIRATION DATE month year CVS Code (on the back of the card, last 3 digits) ZIP CODE USED ON CARD BILLING SIGNATURE OF CARD HOLDER

Participant s Name MEDICAL INSURANCE INFORMATION complete every line or enter NA if it does not apply. Camper must have a medical insurance policy in place during camp.

4 Participant s Name MEDICAL INSURANCE INFORMATION complete every line or enter NA if it does not apply. Camper must have a medical insurance policy in place during camp. This participant is covered by family medical and/or hospital insurance Y N Date of Birth Year of HS Graduation School Attending in the Fall 2017 POSITION CIRCLE DESIRED POSITION QB RB WR OL DL LB DB Primary Insurance Company Primary Insurance Phone Number Primary Insurance Policy Number Primary Subscriber s Name Are you an athletic (letter) award winner in any sport? Yes No Has any WSU athletic coach contacted you by phone more than one time? Yes No Parent/Guardian with decision making authority in the event of illness or injury Address City State Zip Home Phone address Cell Phone HEALTH CARE PROVIDERS - complete every line or enter NA if it does not apply. Participant s Primary doctor(s) Phone Secondary Insurance Company Secondary Insurance Company Phone Number Secondary Policy Number Secondary Subscriber REQUIRED: Name of another person to contact in case of emergency if you are not available: We must have the name & contact info for another adult with legal responsibility in case of illness/injury. Name Phone Relationship to participant In an emergency requiring medical attention or a situation reasonably believed to be an emergency by Washington State University (WSU) authorized agents including event staff; I authorize WSU and its authorized agents to obtain emergency medical care for my child. I will be responsible for any expenses incurred in so doing including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. Participant s Primary dentist(s) Phone NOTE: Minors may consent to certain services in Washington. Participant s Orthodontist(s) Phone Additional health care provider(s) name(s) and contact numbers I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and the event staff from decisions to seek emergency treatment. I voluntarily sign this authorization in consideration for permission for my child to participate in WSU Football Camps. I have read it, and I understand its content and significance. MEDICAL ALERTS - Severe allergies / life threatening conditions / chronic illnesses Signature of Parent/Guardian (For participant less than 18 years of age) Date Signature of Participant(For participant 18 years of age or older) Date Witness Signature(an adult able to verify the above signatures) Date

5 WSU Football Camp Participant Health Form Mail this form to address below: Football Office 510 CFC P O Box Pullman, WA Participant Name: First Middle Last Attendance date(s): Male Female Birth Date Age on arrival at camp: (Month / Day / Year) To Parent(s)/Guardian(s): Please keep a copy for your records. Participant Home Address: Street Address City State Zip Code Parent/guardian with residential placement and/or decision-making authority in the event of illness or injury: Name: Relationship to Participant: Preferred Phones: ( ) ( ) Home Address: (If different from above) Street Address City State Zip Code Second parent/guardian with legal responsibility/authority to be contacted in case of illness or injury, if available: Name: Relationship to Participant: Preferred Phones: ( ) ( ) Additional emergency contact (optional): Name: Relationship to Participant: Preferred Phones: ( ) ( ) Pre-Existing Medical Conditions: Has the camp participant had, or currently have, any of the following? Concussions Y N Heat Illness Y N Surgery Y N Current Orthopedic Injury Y N Sickle Cell / Trait Y N Asthma Y N Epilepsy Y N Diabetes Y N Heart Condition (ie. HCM) Y N ADD / ADHD Y N Other Y N If you answered yes to any of the above questions please explain in the General Health Information section or attach additional information. Immunizations: My child is up-to-date on his/her immunizations and tetanus shots as required by Washington State law. My child has an immunization exemption on file with his/her school. I understand and accept the risks to my child from not being fully immunized.

6 General Health Information: NOTE: It is strongly recommended that parents/legal guardians consult a physician prior to allowing their child to participate in physical activity. Are there any medical concerns which the camp staff should be aware of? Attach additional information if needed. Allergies: No known allergies. This participant is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other This participant has a life-threatening allergy. An emergency care plan signed by physician is required. Please describe below, in detail, what the participant is allergic to, the reaction seen & any preventive or responsive measures utilized (ie. medications). Attach additional forms if necessary. Disability: Does the participant require reasonable accommodation for a disability in order to access or be part of the activities?

7 Medication Mini Camp: Unfortunately, we will be unable to administer medication to children participating in day camps. If your child requires a dosage during camp hours, please make appropriate arrangements. Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. This participant will not take any daily medications while attending the activities. Medication Overnight Campers: Medication is any substance a person takes to maintain and/or improve their health. This includes all prescription medication, as well as all over-the counter drugs that are potentially hazardous if misused (e.g., Tylenol, aspirin, cough medicine, cold tablets, vitamins & natural remedies. All medications must be in their original containers. Prescriptions must have the child s name and how the medication should be given printed on the prescription container. Please send only those medications that are necessary. Participants are required to turn medications into staff upon arrival. This participant will not take any daily medications while attending the activities. This participant will be self-administering the following daily medication(s) while attending the activities under staff supervision. 1 Name of medication Date started Reason for Taking When it is given Amount or dose given Breakfast Lunch Dinner Other time: Breakfast Lunch Dinner Other time: Breakfast Lunch Dinner Other time: How it is given Comments Health History Verification: This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all program activities except as set forth by me and/or an examining physician. If you fail to advise WSU of a medical condition, risks to your child may increase. I understand the information on this form will be shared on a need to know basis with WSU staff and volunteers. I give permission to photocopy this form. In addition, the health care provider has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. Signature of Primary Residential Parent: Date: Parent/Guardian (please print name): Relationship to Participant: Parent/Guardians: Keep a copy for your records. 1 Note: These provisions regarding administration of medication shall not abrogate minors rights to provide their own consent to certain services under Washington law.

8 ASSUMPTION OF RISK I understand that there are risks in participating in recreational activities and educational workshops at the Washington State University (WSU) Athletic Camp / Clinic. In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks that exist, including the risk of death or injury to my child or loss or damage to my property. I understand that there may be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks. Risks in participating in the WSU Football Camp activities, include, but are not limited to: temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage damage, orthopedic damage, severe head, brain, neck or spinal injuries, paralysis, loss or use of arms and/or legs, eye damage, disfigurement, or death. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of traveling to or from the WSU Football Camp activities that cannot be specifically listed. Further, I recognize that the actions of other participants in the activity may cause harm or loss to my child or property. EMERGENCY MEDICAL RELEASE In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU) authorized agents including WSU Football Camp staff to be an emergency; I authorize WSU and its authorized agents to obtain emergency medical care for my child. I will be responsible for any expenses incurred in so doing including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and the staff of WSU Football Camp from decisions to seek emergency treatment RELEASE OF LIABILITY I release, the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses to person or property, which I may sustain and/or sustain as a result of death or injury of my child, as a result of or connected with participation in the above event. My child s participation includes, but is not limited to, travel to and from the event in a private or public vehicle, any activity connected with the event itself, and use of state equipment or facilities for the event whether on or off WSU property. I have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am aware that this document is a contract with WSU and the program sponsors. I sign it freely and voluntarily. Signature of Parent / Guardian: Date: Parent / Guardian (please print): Witness Signature: Date: Witness Name (please print):

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