BLAZER BASEBALL 2017 FALL ACADEMY

Transcription

1 BLAZER BASEBALL 2017 FALL ACADEMY The Blazer Baseball Academy is open to students in grades 8 through 12. Dates: August 15 - September 14 (Games will begin on August 21st - Players will play two games/week) Times: Location: Cost: Monday, Tuesday, Thursday (Schedule will be released once workouts are complete) 5:30 p.m. - 7:00 p.m. 7:15 p.m. - 8:45 p.m. Billy Grant Field $200 includes Fall Exposure Camp enrollment, game jersey, and instruction The Academy will begin with a pro-style workout and information session on Tuesday, August 15 at 5:30 p.m. 60-yard time Throw from position Fielding evaluation Batting practice Bat speed calculation Arm strength evaluation All players will receive a written evaluation of their skills during the Fall Exposure Camp. Hitting instruction with VSU coaches is available each Wednesday during the Academy. Instruction will be done in the indoor hitting facility from 5:30 p.m. - 7:00 p.m. Players who are interested can pay as they go for $20 for a 30-minute session. Each Academy game will be conducted like a VSU intrasquad game: Pregame stretching Complete stats Prescribed throwing In-game instruction Five/Six batters faced per inning Arm care instruction Registration Information - Deadline for registration is Tuesday, August 15th Camper Name Cell Number Home Address City State Zip Code Age Grade School Address Positions: Bats: R L Jersey Size: M L XL XXL The registration form and complete 11-page Participant/Parent Paperwork Form with a copy of their insurance card must be completed for each camper. Please send registration form, Participant/Parent Form, and payment to: VSU Baseball, 1500 North Patterson Street, Valdosta, GA or bring it by the baseball office at 2601 North Patterson Street. PLEASE MAKE CHECKS OUT TO: VSU FOUNDATION - MEMO: BASEBALL

2 MEDICAL HISTORY FORM / RELEASE AND WAIVER OF LIABILITY ALL AREAS OF THIS FORM MUST BE COMPLETED AND SIGNED PRIOR TO CAMP PARTICIPATION CAMPER LAST Name FIRST Name Nickname Date of Birth (mm/dd/yyyy) Grade Parent/Guardian Name(s) Relationship Does camper have allergies? No Yes List: Is camper currently on medications? No Yes List: Does camper have loss of a paired organ (kidney, eye, etc.)? No Yes List: If you have answered YES to any of the above, you must include a physician s permission to participate. IN CASE OF EMERGENCY Please list phone numbers in order of preference; check phone type. PRIMARY CONTACT Relationship Cell Work Home Cell Work Home SECONDARY CONTACT Relationship Cell Work Home Cell Work Home OTHER CONTACT Relationship Cell Work Home Cell Work Home Medical Insurance Company Name Policy Holder Name Policy Number Any instructions regarding your insurance: I/We, the undersigned, herby certify that I/we am/are the parent/legal guardian of the camper. I hereby give permission for the staff of the Camp to seek, during the period of Camp, appropriate medical attention for the camper and for medical attention to be given and for the camper to receive medical attention in the event of an accident, injury or illness. I will be responsible for any and all costs of medical attention and treatment. I/We, the undersigned, for ourselves and/or as guardians of (camper name) understand that baseball is an active, physical sport and that injuries can take place during play. I/We also understand that there will be a number of children attending camp, there will be a limited number of coaches and/or counselors, and my/our child cannot receive individualized attention and supervision all of the time. I/We understand that, as with any sport, injuries can occur, and we hereby acknowledge that my/our child is physically fit and mentally capable of participating in these camp activities. I/We also understand that it is my/our responsibility in caring for the camper listed above, to be assured that he/she is fully capable of engaging in this sport s activity, and I/we are confident that he/she is able to engage in such sport. For the sole consideration of my child s participation in the Camp as outlined, above I agree to indemnify and hold harmless Valdosta State University and the Board of Regents of the University System of Georgia their members individually and their officers, agents, and employees (current and former) from any and all claims, demands, claims for attorney s fees whatever kind or nature which might be assorted against them, rights and causes of actions of whatever kind, by or on behalf of myself, my heirs, assigns, attorneys in fact, attorneys at law, personal representatives, dependents, or otherwise, arising from my Child s participation in connection with his/her activities at and through Valdosta State University. I hereby certify that I am eighteen (18) years of age or older, suffering under no legal disabilities, that I have read the foregoing document carefully and hereby sign this agreement voluntarily and of my own free will. Parent/Guardian Signature PRINT Parent/Guardian Name Date Please complete this form and return it with your registration and payment to reserve your space.

3 VSU PROGRAMS SERVING MINORS VSU Authorization to Administer Medication I. Personal/Medication Information (please print) Today s Date: Participant Name: Age: Allergies/Medications: Are you allergic to or do you have any adverse reaction to any of the following? Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain List all medication currently used, including any over-the-counter medications. Medication Dose Frequency Reason Special Storage Instructions: Parent/Guardian Name: Parent/Guardian Phone Numbers Home: Cell: Work: Name of Licensed Prescriber/Physician: Phone: II. Authorization for Medical Care I hereby authorize the program staff to administer my child the above-listed medication. I understand that medication, whether over-the-counter or prescription, should be kept in original containers. Prescription medication containers should bear the pharmacy label, date of filling, pharmacy name and address, patient name, name of prescribing practitioner, name of prescribed medication, directions for use and cautionary statements, as originally appeared on the container. When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed. Prior to the beginning of the program, the Minor Coordinator shall arrange access to emergency medical services through the University Health Services, South Georgia Medical Center or other provider as appropriate for the size and complexity of the program, upon request of the Program Administrator. Medical care appropriate for the nature of the events, expected attendance and other variables should be discussed with the Director of University Health Services. Valdosta State University does not provide medical insurance to cover medical care for the minor. Page 1 of 11

4 For sudden onset illness, participants should be seen by the on-duty staff during regular business hours of the University Health Center for triage and further medical care as appropriate. After business hours issues will be forwarded for Emergency care. If prior approval for medicine distribution is requested by the Program Administrator and agreed to, the following minimum conditions will apply: 1. The participant s family provides the medicine in its original pharmacy container labeled with the participant s name, medicine name, dosage and timing of consumption. Over-the-counter medications must be provided in their manufacturers container. 2. The Program Administrator shall keep the medicine in a secure location, and at the appropriate time for distribution shall meet with the participant. 3. The Program Administrator shall allow the participant to self-administer the appropriate dose as shown on the container. 4. Any medicine which the participant cannot self-administer, must be stored and administered by a licensed healthcare professional associated with the campus or, if no one is available, arrangements must be made with another health care professional in advance of the participant s arrival. 5. Personal epi pens and inhalers may be carried by the participant during activities. 6. Follow guidance from University Health Services concerning communicable diseases. 7. The Program Administrator should consult with the Office of Social Equity which houses the University s ADA Coordinator to discuss reasonable accommodations if necessary before the start of the program. 8. Neither the Program Administrator or the Minor Coordinator or any other VSU employees shall provide medical advice to any of the participants including, but not limited to, the distribution of over the counter medications, prescription or other medical treatment By signing this form I hereby acknowledge that all information is accurate and current, that all pertinent and important medication information is listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in the above information in a timely and reasonable manner. I hold harmless and agree to indemnify the program and Valdosta State University, as well as the Board of Regents, from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. Signature of Parent or Guardian: Parent/ Guardian Name: Date: Page 2 of 11

5 VSU Medical Information Form and Authorization for Medical Care I. Basic Personal Information (Please Print) Today s Date: Participant Name: Age: II. Parent/Guardian Name: Street Address/P.O. Box: City: State: Zip: Home: Cell: Work: Address Emergency Contact Information Person to notify in case of emergency: Relationship: Contact Phone Numbers: & Street Address/P.O. Box: City: State: Zip: Participant s Physician: Phone: Insurance Provider: Phone: Insurance Policy Number: (Note: The institution does not offer any form of health, liability, or other types of insurance for participants. Please attached a copy of the front and back of your insurance card with this form.) III. Medical Information Please list any current medical concerns or medical history we need to know about your child: (Ex. Past injuries, current conditions, physical limitations, etc.) Allergies/Medications: Are you allergic to or do you have any adverse reaction to any of the following? Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain List all medication currently used, including any over-the-counter medications. Medication Dose Frequency Reason Does your child need any accommodations to safely participate in the program? If yes, please explain: Does your child require any assistance with his/her medications? If so, please explain: Page 3 of 11

6 Medical Care Policy Prior to the beginning of the program, the Minor Coordinator shall arrange access to emergency medical services through the University Health Services, South Georgia Medical Center or other provider as appropriate for the size and complexity of the program, upon request of the Program Administrator. Medical care appropriate for the nature of the events, expected attendance and other variables should be discussed with the Director of University Health Services. Valdosta State University does not provide medical insurance to cover medical care for the minor. For sudden onset illness, participants should be seen by the on-duty staff during regular business hours of the University Health Center for triage and further medical care as appropriate. After Business hours issues will be forwarded for Emergency care. If prior approval for medicine distribution is requested by the Program Administrator and agreed to, the following minimum conditions will apply: IV. 1. The participant s family provides the medicine in its original pharmacy container labeled with the participant s name, medicine name, dosage and timing of consumption. Over-the-counter medications must be provided in their manufacturers container. 2. The Program Administrator shall keep or arrange to keep the medicine in a secure location, and at the appropriate time for distribution shall meet with the participant. 3. The Program Administrator shall allow the participant to self-administer the appropriate dose as shown on the container. 4. Any medicine which the participant cannot self-administer, must be stored and administered by a licensed healthcare professional associated with the campus or, if no one is available, arrangements must be made with another health care professional in advance of the participant s arrival. 5. Personal epi pens and inhalers may be carried by the participant during activities. 6. Follow guidance from University Health Services concerning communicable diseases. 7. The Program Administrator should consult with the Office of Social Equity which houses the University s ADA Coordinator to discuss reasonable accommodations if necessary before the start of the program. 8. Neither the Program Administrator of the Minor Coordinator or any other VSU employees shall provide medical advice to any of the participants including but not limited to, the distribution of over-the-counter medications, prescription or other medical treatment. Authorization for Medical Care I understand that my child is voluntarily participating in a program being held at Valdosta State University. By signing this form, I hereby acknowledge that all information is accurate and current, that any activity restrictions, allergies, and medications are listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in my child s mental, physical, or medical condition before the program begins. I understand that Valdosta State University does NOT provide medical insurance for my child and that I should consult my child s physician before allowing my child to participate in this program. In the case of accident or illness, I hereby authorize the program staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. I hold harmless and agree to indemnify the program, Valdosta State University and the Board of Regents from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my child s participation in such voluntary program. Participant Name: Signature of Parent or Guardian: Parent or Guardian Name: Date: Page 4 of 11

7 Program/Activity/Camp Name: Participant Name: Parent/Guardian Name (Please Print): PARTICIPANT CODE OF CONDUCT The Program has established rules and standards of conduct for all Participants. It is the responsibility of the Parent/Legal Guardian and the Participant to review the Program rules and standards of conduct. Dismissed Participants are not eligible for a refund of any fees or expenses. The Parent/Legal Guardian is responsible for all costs associated with removing the Participant from the Program due to his/her misconduct, including but not limited to transportation costs to return the Participant home. Expectations of Behavior & Conduct: 1. Participants are expected to be respectful of others. No violence, including sexual abuse or harassment, will be tolerated. Hazing of any kind is prohibited. Bullying including verbal, physical, and cyber bullying are prohibited. 2. The inappropriate use of cameras, imaging, and digital devices is prohibited, including use of such devices in showers, restrooms, or other areas where privacy is expected by participants. 3. The possession or use of alcohol and other drugs, fireworks, guns and other weapons is prohibited. 4. Use of tobacco products is prohibited on all University property. 5. Misuse or damage of University property is prohibited. Charges will be assessed against those participants who are responsible for damage or misuse of University property. 6. No theft of property, regardless of owner, will be tolerated. 7. The operation of a University motor vehicle by minors is prohibited while attending the program. 8. The parking of staff and participant vehicles must be in accordance with University parking regulations. 9. Rules and procedures governing when and under what circumstances participants may leave University property during the program must be made explicit by the Program Administrator and communicated in writing to program participants, staff and to the Minor Coordinator. 10. Any Authorized Adult or Program Staff or other Mandatory Reporter, who, under Georgia law has reasonable cause to believe that suspected child abuse has occurred, shall immediately report the suspected abuse to the Valdosta State University Police Department and the appropriate supervisor or Program Administrator who is able to take immediate action. (The USG further expects that any other USG employee, whether a Mandatory Reporter or not, will also appropriately report suspected child abuse.) The institution must ensure that the Division of Family and Children Services is notified of the suspected abuse immediately and in no case later than 24 hours after the Authorized Page 5 of 11

8 Adult or Program Staff (or other reporter) first had reasonable cause to suspect the abuse. 11. If the Authorized Adult believes that the Program Administrator and/or the Minor Coordinator may be involved in the allegations of assault or abuse, they shall inform University Police directly. PARTICIPANT AGREEMENT I understand that as a condition for participating in the Program I must comply with the Program s rules and standards of conduct and follow all reasonable direction of the Program Staff. Failure to comply with the Program s rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my being dismissed from the Program. Participant Signature: Date: PARENT/LEGAL GUARDIAN AGREEMENT I understand that my child will be subject to the rules and standards of conduct of the Program, Valdosta State University and the University System of Georgia. I further understand that my child s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my child s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited to transportation costs to return the Participant home. I understand that Dismissed Participants are not eligible for a refund of any fees or expenses. Parent/ Guardian Signature: Date: Page 6 of 11

9 VSU Participation Agreement and Waiver Form for Minors PROGRAM/ACTIVITY INFORMATION Program/Activity/Camp Name Date(s) Location PARTICIPANT INFORMATION Participant Name Address Phone Date of Birth Gender RELEASE, WAIVER OF LIABILITY, AND COVENANT NOT TO SUE I (Parent/Guardian Name), the parent or legal guardian of the Participant, (Minor Name), for the sole consideration, the sufficiency of which is hereby acknowledged, of the right to participate in the event or program described as (the Program/Activity/Camp Name), do hereby agree to the following relating to the Program. I fully and voluntarily consent to my child s participation in the Program. I hereby acknowledge my awareness that participation in the Program may expose me/my child to risk of property damage, bodily or personal injury. Participation could include certain physical activities such as but are not limited to athletic camps, after school programs, science camps, music camps, enrichment activities, swimming, lifting, crossing streets, parking lots and intersections. I understand that the risks that I/my child may encounter include, but are not limited to transportation accidents, injury from falls, injury in inclement weather, bumps, bruises, cuts and abrasions, muscle strains and sprains, and exposure to contagious diseases which may cause death, as well as other risks that may not be foreseeable. I knowingly and freely assume any and all such risks. Injury, Illness, and Medication Protocols: Prior to the beginning of the program, the Minor Coordinator shall arrange access to emergency medical services through the University Health Services, South Georgia Medical Center or other provider as appropriate for the size and complexity of the program, upon request of the Program Administrator. Medical care appropriate for the nature of the events, expected attendance and other variables should be discussed with the Director of University Health Services. Valdosta State University does not provide medical insurance to cover medical care for the minor. For sudden onset illness, participants should be seen by the on-duty staff during regular business hours of the University Health Center for triage and further medical care as appropriate. After Business hours issues will be forwarded for emergency care. In exchange for being allowed to participate in the Program, I hereby release and forever discharge and agree to indemnify the Valdosta State University, the Board of Regents of the University Page 7 of 11

10 System of Georgia, its members individually and their officers, agents and employees from any and all claims, demands, rights, expenses, actions, and causes of action, of whatever kind, arising from or by reason of any personal injury, bodily injury, property damage, or the consequences thereof, whether foreseeable or not, resulting from or in any way connected with my participation in the Program. I further covenant and agree that for the consideration stated above, I will hold forever harmless and will not take legal action against the Valdosta State University, the Board of Regents of the University System of Georgia, its members individually, and their officers, agents, and employees for any claim for damages arising or growing out of my participation in this activity whether caused by negligence or otherwise. I understand that the acceptance of this Release, Waiver of Liability, and Covenant not to sue shall not constitute a waiver, in whole or part, of sovereign immunity by the Board of Regents of the University System of Georgia, its members, officers, agents, and employees. I certify that I understand and have read the above carefully before signing. I acknowledge and represent that I freely and voluntarily sign this Agreement, and that it is my express intent that this Agreement shall contractually bind my heirs, executors, administrators, and assigns, and my child s heirs, executors, administrators, and assigns, as well as myself and my child. Parent/ Guardian Name: Parent/ Guardian Signature: Date: Page 8 of 11

11 VSU Photograph & Video Release Form I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. Photographic, audio or video recordings may be used for the following purposes: conference presentations educational presentations or courses informational presentations on-line educational courses educational videos or institutional marketing materials By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only. AUTHORIZATION AND WAIVER OF LIABILITY The undersigned hereby acknowledges that participation in risk-oriented programs and activities involves an inherent risk of physical injury and assumes all risks. The undersigned hereby agrees that for the sole consideration of the Valdosta State University (also referred to as "Institution") allowing the undersigned to participate in these programs and activities for which or in connection with which the Institution has made available any facilities, equipment, grounds, or personnel for such programs or activities or to the undersigned while participating in any such programs for activities, the undersigned does hereby release and forever discharge the Valdosta State University and the Board of Regents of the University System of Georgia, its member individually, and its officers, agents and employees of any and from all claims, demands, rights and causes of action of whatever kind or nature, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, resulting from any participation in any way connected with such programs and activities. I further covenant and agree that for the consideration stated above I will not sue the Institution, the Board of Regents of the University System of Georgia, its members individually, its officers, agents, or employees for any claim for da mages arising or growing out of my voluntary participation in above said activities. I understand that the acceptance of this release and covenant not to sue the Institution or the Board of Regents of the University System of Georgia shall not constitute a waiver in whole or in part, of sovereign or official immunity by said Board, its members, officers, agents, and employees. Further, I understand that this release, waiver of liability, and covenant not to sue shall be effective during the entire period of my enrollment at the institution or participation in risk related activity. I have received a copy of this document and I have read the above carefully before signing. Page 9 of 11

12 By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. Participant Name: Participant Signature: Date: If this release is obtained from a presenter under the age of 18, then the signature of that presenter s parent or legal guardian is also required. Signature of Parent or Guardian: Parent/ Guardian Name: Date: Address/PO Box: City: State: Zip: Parent/ Guardian Phone Numbers Home: Cell: Work: Address Page 10 of 11

13 VSU Pick Up Authorization I. Personal Information (please print) Today s Date: / / Participant Name: Age: Parent/Guardian/Name: Phone: Work Phone(s): Cell Phone(s): Home II. Authorized Pick Up Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age. The above-named child will not be permitted to leave the program with anyone who is not listed below. Authorized individuals must pick up the child in person and may be requested to show identification to program staff. Children will not be released to persons who fail to provide acceptable identification upon request. I authorize the following responsible persons to pick up my child from the program (attach additional pages as needed): Authorized Person Phone Number Relationship to Child Please note that children must be picked up by designated times. If an authorized adult is unable to be reached, program members will contact the local police department as a last resort to take your child home. If you are not at home, your child may be released to the Division of Family and Children Services. III. Authorized Dismissal My child is at least 16 years of age and will be responsible for his/her own transportation to and from the program. My child may sign himself/herself out at the end of the program activities. Signature of Parent or Guardian: Parent/Guardian/Name *: *Please note that only the enrolling parent will be permitted to complete this form. Page 11 of 11