Patriot Pole Vault Club Athlete Information
Athlete's First Name *
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Athlete's Last Name *
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Athlete's USATF Membership Number *
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Athlete's USATF Membership Expiration Date *
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Athlete's Pole Vault Experience Level (years)
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Athlete's PR
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Athlete's Birthday *
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Athlete's School *
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Athlete's Year of Graduation *
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Parent's/Guardian's Names *
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Parent's/Guardian's E-Mail Address
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Parent's/Guardian's Phone Number
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Athete's E-Mail Address
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Home Address *
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City *
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State *
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Zip Code *
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Home Phone Number *
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Emergency Contact *
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Emergency Contact Phone Number *
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Please list any medical concerns such as prior or current athletic injuries, allergies or any other health conditions we should know about
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By clicking "Yes" I hereby grant permission for myself/my child to attend Patriot 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 Coaches Douglas Lang, Ignacio Arguello, Ingrid Gustafson, Ken Petersen, Jim Tylock, Jay Weber, Kelsey Weber, Kurt Riska, Nathaniel Bogan, Anthony Innamorati, Paul Snyder, Melissa Leslie, Greg Bourque, Dan Conti, Dave Gibeault, James Gruenbacher, Mark Hathaway, Nick Parsons, Chanra Kao, Nelson Laskoski and any other associated coach, our mentoring staff, Westborough High School, or any other pole vault practice or competition facility used by the Patriot 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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