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Northern Virginia Pole Vault Club Athlete Registration & Information Form
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Athlete's First Name *
Athlete's Last Name *
Athlete's USATF Membership Number *
Have You Ever Pole Vaulted Before? *
Athlete's PR (if applicable, put N/A if never vaulted before) *
Athlete's Age *
Athlete's School (if applicable) *
Parent's/Guardian's Names *
Parent's/Guardian's E-Mail Address *
Athlete's Email Address *
Athlete's Phone Number *
Emergency Contact Name & Phone Number *
Please list any medical concerns such as prior or current athletic injuries, allergies, or any other health conditions we should know about *
By clicking "Yes" I hereby grant permission for myself/my child to attend Northern Virginia Pole Vault Club practices and events. I verify that I/my child has had a physical exam in the past year and is capable to participate in the activities related to pole vaulting. I agree to indemnify, hold harmless and defend Coach Decker Barborek, and any other associated coaches of the Northern Virginia Pole Vault Club, our mentoring staff, George Mason University, or any other pole vault practice or competition facility used by the Northern Virginia Pole Vault Club, their agents, employees and sponsors from any and all liability for injury to myself or my child as well as any damage caused by myself and/or my child. I understand that track and field, and in particular pole vaulting, are potentially dangerous and could pose risk to injury during the course of instruction or competition. Sports by their very nature pose the continuous threat of injury that no type of equipment can ensure against or prevent. Should medical attention be necessary, I hereby authorize any physician or trainer selected by club personnel to conduct medical or surgical procedures. 
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