WASHINGTON STATE COUGARS

Tennis Camp

Note: fields with an * must be filled out.

ADULT CAMP, Dates: June 23-25, 2014 (6:00-8:00 p.m.). Cost: $125


You may pay in full or pay a nonrefundable $30 deposit with the balance due at check-in.
Pay in full now (a 2% credit card processing fee will be applied).
Make a nonrefundable deposit with the balance due at check-in.
Check here if you attended the WSU tennis camp last year and receive $20 off registration.


On or before June 7, 2014 refunds will be made on camp registration less a $30 processing fee.

After June 10, 2014 refunds will be made with a medical note only minus the processing fee.

*First Name: *Last Name:

*Email:

*Preferred Phone:( ) - Secondary Phone:( ) -

*Address: *City: *State: *Zip:

First Name: Last Name:

Preferred Phone:( ) - Secondary Phone:( ) -

Have you had, or currently have, any of the following?

Concussions Heat Illness Surgery Current Orthopedic Injury
Sickle Cell / Trait Asthma Epilepsy Diabetes
Heart Condition (ie. HCM) ADD / ADHD Other No Previous or Current Medical Conditions

If you answered ‘yes’ to any of the above questions please explain below in the "General Health Information" section or submit additional information.

No known allergies.

This participant is allergic to:
 Food     Medicine     The environment (insect stings, hay fever, etc.)     Other
This participant has a life-threatening allergy.  An emergency care plan signed by physician is required.

Please describe below in the "General Health Information" section what the participant is allergic to, the reaction seen & any preventive or responsive measures utilized (ie. medications).

NOTE: It is strongly recommended that participants consult a physician prior to to participating in physical activity.

Are there any medical concerns which the camp staff should be aware of? Submit additional information if needed.

This health history is correct and accurately reflects the health status of the participant to whom it pertains. If you fail to advise WSU of a medical condition, risks may increase. I understand the information on this form will be shared on a "need to know" basis with WSU staff and volunteers. I give permission to photocopy this form. In addition, the health care provider has permission to obtain a copy of my health record from providers who treat me and these providers may talk with the program's staff about my health status.

 

Name of participant's primary doctor: Phone: ( ) -

Name of dentist: Phone: ( ) -

Name of orthodontist: Phone: ( ) -

Additional health care provider(s) name(s) and contact numbers:

*This participant is covered by family medical and/or hospital insurance: Yes     No

  Primary Insurance Secondary Insurance
Company:
Policy Number:
Subscriber:
Insurance Company
Phone Number:
( ) - ( ) -

 

I understand that there are risks in participating in recreational activities and educational workshops at the Washington State University (WSU) Athletic Camp / Clinic.

In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks that exist, including the risk of death or injury or loss or damage to my property.  I understand that there may be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks.

Risks in participating in WSU Camp activities, include, but are not limited to:  temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage damage, orthopedic damage,  severe head, brain, neck or spinal injuries, paralysis, loss or use of arms and/or legs, eye damage, disfigurement,  or death.  I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of traveling to or from WSU Camp activities that cannot be specifically listed.  Further, I recognize that the actions of other participants in the activity may cause harm or loss to my child or property.

In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU) authorized agents including WSU Camp staff to be an emergency; I authorize WSU and its authorized agents to obtain emergency medical care for me.  I will be responsible for any expenses incurred in so doing including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my health record from providers who treat me and these providers may talk with the program’s staff about my health status.

I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and the staff of WSU Tennis Camp from decisions to seek emergency treatment.

I release, the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses to person or property, which I may sustain and/or sustain as a result of death or injury as a result of or connected with participation in the above event.  My participation includes, but is not limited  to, travel to and from the event in a private or public vehicle, any activity connected with the event itself, and use of  state equipment or facilities for the event whether on or off WSU property.  I have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am aware that this document is a contract with WSU and the program sponsors.  I enter this contrac freely and voluntarily.

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Washington State University Athletics, PO Box 641602, Washington State University, Pullman WA 99164-1602, 509-335-0342, Contact Us