Spring Clinic Registration
20th Annual Pole Vault Clinic
February 16, 2019
9am-12pm (check in at 8:45am)
Pole Pilots Track Club 1137 E. Edison Street, Tucson AZ 85719
Vaulter Information
Name *
First and last name
Your answer
Birthdate *
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
Current PR (personal record)
Your answer
High School / Coach
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
Name(s)
Your answer
Email
Your answer
Home address
Please include zip code.
Your answer
Phone number(s)
Please indicate preferred number.
Your answer
Waiver
I hereby grant permission for myself/child to attend the Pole Pilots Pole Vault Clinics. I verify that I/my child had a physical exam in the last year and am/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, , USAT&F, 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 *
Your answer
Date *
Your answer
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