Pole Pilots Registration
Vaulter Information
Name *
First and last name
Your answer
Email
Your answer
Birthdate *
If you are interested in competitions, we need to keep a copy of your birth certificate on record to verify your age at meets. You are not required to compete.
MM
/
DD
/
YYYY
Height *
Your answer
Weight *
We want to be sure you only vault on poles that are safe for your weight.
Your answer
Allergies, prior injury, or health conditions *
Do you have any allergies, prior athletic injuries, or health conditions we should know about? We respect your privacy and will keep this information confidential. If yes, please specify.
Your answer
Parent/Guardian Information
Required if athlete is under 18.
Name(s)
Your answer
Email
Your answer
Home address
Please include zip code.
Your answer
Phone number(s)
Please indicate preferred number.
Your answer
Emergency Information
USATF provides secondary medical/liability insurance. You are required to have sufficient medical coverage to undertake this activity.
Health Insurance Carrier *
Your answer
Group / Policy *
Your answer
Primary Physician and Phone Number *
Your answer
For High Schoolers
High School
Your answer
High School Coach
Please talk to your coach about summer vaulting. We don't want any confusion or conflicts!
Your answer
Current PR (personal record)
Your answer
Yes
No
Maybe
Will you be training year round?
Do you do any other sports?
Waiver
I hereby grant permission for myself/child to attend Pole Pilots. I verify that I/my child had a physical exam in the last year and is capable of participating in the activities related to pole vaulting. I agree to indemnify, hold harmless, and defend Jen Croissant, Roy D. Willits, Jr., Pole Pilots, Salpointe Catholic High School, USATF, their agents, employees, and sponsors from any and all liability for injury to myself/child. I understand that track and field and in particular pole vaulting and many of its related activities are potentially dangerous and could pose risk of injury. Should medical attention be necessary, I hereby authorize any physician or trainer selected by club personnel to conduct medical, first aid, or surgical procedures.

I have read and understood, and I agree with the informed consent and release outlined above as it relates to myself/son/daughter.

Please provide a signature by typing your name and the date in the boxes below.

Participant's signature *
Your answer
Date *
Your answer
Parent / Guardian signature
Required if athlete is under 18.
Your answer
Date
Your answer
Submit
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