Shooting:Jason Rostan, H-SC 2003 and Assistant Coach, 1st Team All-American and ODAC Player of the Year
Face-offs:Jake Plunket, Asst. Coach H-SC, 2005 Syracuse University and member of the 2008 Rochester Rattler MLL Championship
Defense:Mike Plantholt, Head Coach, Randolph-Macon College, National Defenseman of the Year and 1st Team All-American
Goalie Play:Scott Ketcham, Head Coach, Randolph College, 1999 NCAA Statistical Leader while at H-SC
Camp director Ray Rostan is the Head Coach at Hampden-Sydney College, since 1984. Coach Rostan was named the National Coach of the Year in 1989 and 1998. He was the defensive coordinator for the 2002 USA World Championship Team, a former member of the 1974 NLL Rochester Griffins Pro Indoor Championship team, and played on the 1973 D-III National Championship team as an attack- man while at Cortland State.
Hellmuth-Pritzlaff Lacrosse Stadium, a new state of the art Field Turf field, will be on of the great fields utilized by our campers
Street Address__________________________________________________________
Town or City___________________________________ State____ Zip__________
Telephone( )___________________ Year
in School 2009-2010 ________________
High
School or Club______________________ Coach's
name_____________________
Lacrosse
Position___________________
Roommate Request:
(1st Choice )_____________________ (2nd Choice)______________________
You must both request each other. We cannot guarantee that you will be in the same room as all friends, yet we will place you as close together as possible.
***Please
return this form with the $410 overnight camper fee or $250 non-refundable deposit with a balance
of $160 and a separate
key & damage deposit check for $60 refundable when room key is returned. Mail
to: Ray Rostan, Performance School, 1001 Meadowview Lane, Farmville, VA
23901. Checks Payable To: Ray Rostan-Performance School (due by July 1, 2009)
PARENTAL STATEMENT:
I
hereby verify that my child is physically fit to play the contact sport of Lacrosse. In addition, I authorize
any emergency treatment deemed necessary for my child to be administered by the
provided medical staff and agree not to hold the medical staff, Hampden-Sydney
College, the coaches, or the Hampden-Sydney Performance School staff liable for any
injuries.
Phone: Home ( )_________________________ Phone: Home (
)______________________
Phone: Work ( )__________________________ Phone: Work (
)______________________
Does the applicant have any known allergies to food or medication?
Yes No
If yes, please list the foods and/or drugs:
Give date of the latest DPT or Tetanus Toxoid
injection:_________________________________
Does the applicant have any ongoing disease, physical disability or recurring
illness that may affect or impair participation in the Hampden-Sydney
Performance School?
Yes No
If yes, please attach a physician?s note describing the disability and specific
limitation for participation.
Is the applicant covered by medical insurance? (mandatory as all camp insurance is supplemental)
Yes No
Please list the following:
Name of Insurance Company:__________________________ Policy
#____________________
PARENTAL CONSENT FOR TREATMENT OF MINORS
Please mail in advance
Parental permission must be obtained before medical treatment can be rendered to
a person under 18 years of age. Please read and sign the following consent. No major procedures will be performed except in extreme
emergency, without parents being fully informed. Please
note that your child may not
participate in the Hampden-Sydney Performance School until we receive the signed Parent
Consent form.
I
GIVE PERMISSION TO THE HAMPDEN-SYDNEY PERFORMANCE SCHOOL ATHLETIC TRAINER TO CARRY OUT SUCH EMERGENCY DIAGNOSTIC AND THERAPEUTIC
PROCEDURES AS MAY BE NECESSARY FOR MY SON AND IN THE PHYSICIANS? ABSENCE FOR THE
ATHLETIC TRAINER ON DUTY TO RENDER EMERGENCY CARE IN LINE WITH STANDING ORDERS, AND
ALSO PERMIT SUCH PROCEDURE TO BE CARRIED OUT AT AND BY ONE OF THE LOCAL
HOSPITALS IN THE EVENT THAT MY SON HAS BEEN SENT OR TAKEN THERE FOR EMERGENCY
CARE.
