Patriot Pole Vault Club Athlete Information
Athlete's First Name *
Athlete's Last Name *
Athlete's USATF Membership Number *
Athlete's USATF Membership Expiration Date *
MM
/
DD
/
YYYY
Athlete's Pole Vault Experience Level (years)
Athlete's PR
Athlete's Birthday *
MM
/
DD
/
YYYY
Athlete's School *
Athlete's Year of Graduation *
Parent's/Guardian's Names *
Parent's/Guardian's E-Mail Address
Parent's/Guardian's Phone Number
Athete's E-Mail Address
Home Address *
City *
State *
Zip Code *
Home Phone Number *
Emergency Contact *
Emergency Contact 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 Patriot Pole Vault Club, Patriot Pole Vault Club - Connecticut and Patriot Pole Vault Club - Maine 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, Megan Biscoglio, Nathaniel Bogan, Jacob Borgia, Greg Bourque, John Byrnes, Dan Dachelet, Carley Dykstra, Carlos Fuertes, Connor Green, Ingrid Gustafson, Mark Hathaway, Rachel Hill, John Hoogasian, Anthony Innamorati, Chanra Kao, Nicole Kelly, Lauren Kuntz, Mitch Larose, Morgan Latham, Melissa Leslie, Ann Mann, Nick Parsons, Ken Petersen, Sotirios Pintzopoulos, Kurt Riska, Zoe Rubenstein, Cooper Smelski, Paul Snyder, Kyle Tereso, Jim Tylock, Joe Vetere, Katherine Watts, Jason Weber, Kelsey Weber 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.
Clear selection
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy