| Saturday, July 04, 2009 |
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Performance School Application At Hampden-Sydney College
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Last Name_______________________ First Name____________________________ Parent E-mail ___________________________________________________________ Secondary E-Mail________________________________________________________ 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)______________________ ***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. Parent Signature:_________________________________________ Date__________________
MEDICAL CONSENT FORM Camper's Name__________________________________ Social Sec.#____________________ Birth date_____________________ If an emergency arises, list two people who can be notified: Name____________________________________ Name________________________________ Relationship______________________________ Relationship___________________________ 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 #____________________ Address____________________________________________ Phone ( )_________________
PARENTAL CONSENT FOR TREATMENT OF MINORS 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. WAIVER AND RELEASE: For good and valuable consideration, receipt of which is hereby acknowledged, we the undersigned, for ourselves, our heirs, executors and administrators, waive, release and forever discharge the Lacrosse Performance School at Hampden-Sydney College, its staff, officers, agents, representatives, employees, successors and all rights and claims for damages, resulting from injury or property which may be sustained or occur during participating camp activities and in and around the College campus and living facilities of the camp, or arising from travel to or from camp, whether said damages, injury or loss are due to negligence or not. 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.
SIGNED:____________________________________________ RELATIONSHIP_______________ DATE______________________
Lewis C. Everett Stadium Last modified: 12-22-2008 |
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