WASHINGTON STATE UNIVERSITY
COUGAR FOOTBALL
2014 MINI CAMPS
Date: Saturday, June 14 (12pm to 5pm)
OR
Saturday, June 21 (12pm to 5pm)
Eligible Grades: Any and all entering grades 11th or 12th in the fall of 2014 (no high school graduates allowed)
Location: Washington State University Athletic Facilities, Pullman, Washington
Cost: $50 Includes camp instruction and camp t-shirt.
This non-contact camp will be an afternoon event in which you will have a chance to see the WSU Football facilities,
meet with our coaches, and have the chance to show off your skills with instruction from our coaching staff. You will go
through agility drills, followed by more football specific drills, 1 on 1’s and 7 on 7.
Deadline: Walkups will be taken on a space available basis after completion of all required forms and parent signatures.
Campers must complete all the required forms in this packet including parent signatures before participation. Any
missing information will delay acceptance into the camp. We do NOT require proof of a physical. We do require
campers have their own medical insurance. An athletic trainer will be on duty throughout the entire event. A doctor is
on constant call, and hospital facilities are readily accessible.
Equipment: work out attire, tennis shoes, cleats. Outdoor sessions will be on FieldTurf.
Check-in begins at 12pm in the Bohler Athletic Complex Galleria (main lobby next to weight room). Instruction will
begin at 1pm, moving outside to Rogers Field/Martin Stadium at approximately 2:30pm.
A meal is not provided, so please eat prior to check-in. Water will be available at all times.
Parents/family are welcome to watch the outdoor sessions. Instruction on Rogers Field and/or Martin Stadium will
begin at approximately 2:30pm.
Parking
Make sure you are legally parked. Parking is enforced 24 hours a day, every day. Read the signs as you enter the lot and
make sure it is available for parking on Saturdays. WSU Football will not be responsible for parking violation costs or
appeals. A detailed parking map is included in this packet.
Refund Policy
The payment for the Mini Camp is non-refundable. Refunds are possible for medical emergencies or unforeseen
accidents ONLY. A physician’s letter of explanation prior to the first day of camp must accompany any refund requests.
All potential refund situations will be evaluated at the end of the camp. Approved refunds will be credited after July 15,
2014. Submission of the application indicates acceptance of this policy.
Travel to Pullman
Please visit the WSU Visitor Center for driving directions. www.visitor.wsu.edu
509.335.4636
BY AIR - the Moscow-Pullman Regional Airport is serviced by Horizon Air (an Alaska Airline affiliate).
Please contact our office 48 hours prior to your arrival to arrange transportation from the Moscow-Pullman Regional
Airport.
We will NOT be able to provide transportation from the Lewiston (Idaho) Airport or Spokane International Airport.
There is a shuttle service available from the Spokane Airport (www.wheatlandexpress.com 800.334.2207), however
please contact the shuttle company before booking any travel into/out of Spokane to make sure they will make your
connections.
CONTACT: Phone: 509.335.0250
Email: [email protected]
WSU COUGAR FOOTBALL MINI CAMP
Saturday, June 14 OR Saturday, June 21
NAME OF CAMPER
SCHOOL CAMPER ATTENDS
Method of Payment: $50
Cash
Personal Check #
Money Order #
Charge Card
TOTAL AMOUNT TO CHARGE
NAME ON CARD (print)
CARD NUMBER – VISA OR MASTERCARD ONLY
Visa starts with 4, Mastercard starts with 5
EXPIRATION DATE
month
year
CVS Code (on the back of the card, last 3 digits)
SIGNATURE OF CARD HOLDER
Refund Policy
The payment for the Mini Camp is non-refundable.
Refunds are possible for medical emergencies or
unforeseen accidents ONLY. A physician’s letter of
explanation prior to the first day of camp must
accompany any refund requests. All potential
refund situations will be evaluated at the end of the
camp. Approved refunds will be credited after July
15, 2014.
Contact Information:
Washington State University
102 Bohler Athletic Complex
P O Box 641602
Pullman, WA 99164-1602
Phone: 509.335.0250
Fax: 509.335.4214
Email: [email protected]
Web: www.wsufootballcamp.com
MEDICAL INSURANCE INFORMATION – complete every line or enter NA if it does not apply.
Camper must have a medical insurance policy in place during camp.
Participant’s Name
This participant is covered by family medical and/or hospital insurance
Date of Birth
Year of HS Graduation
School Attending in the Fall 2014
POSITION – CIRCLE DESIRED POSITION
QB
RB
WR
OL
DL
LB
DB
Are you an athletic (letter) award winner in any sport? Yes No
Has any WSU athletic coach contacted you by phone more than one time? Yes No
Parent/Guardian with decision making authority in the event of illness or injury
Y
N
Primary Insurance Company
Primary Insurance Policy Number
Primary Insurance Phone Number
Primary Subscriber’s Name
Secondary Insurance Company
Secondary Policy Number
Secondary Insurance Company Phone Number
Secondary Subscriber
REQUIRED: Name of another person to contact in case of emergency if you are not available:
We must have the name & contact info for another adult with legal responsibility in case of illness/injury.
Address
City
State
Home Phone
Name
Relationship to participant
Phone
email
Zip
Cell Phone
Email address
HEALTH CARE PROVIDERS - complete every line or enter NA if it does not apply.
Participant’s Primary doctor(s)
Phone
Participant’s Primary dentist(s)
Phone
Participant’s Orthodontist(s)
Phone
Additional health care provider(s) name(s) and contact numbers
In an emergency requiring medical attention or a situation reasonably believed to
be an emergency by Washington State University (WSU) authorized agents including
event staff; I authorize WSU and its authorized agents to obtain emergency medical
care for my child. 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 child’s health record from providers who treat my child and these providers may
talk with the program’s staff about my child’s health status.
NOTE: Minors may consent to certain services in Washington.
I hold harmless and agree to indemnify Washington State University, its authorized
agents and employees and the event staff from decisions to seek emergency
treatment.
I voluntarily sign this authorization in consideration for permission for my child to
participate in WSU Football Camps. I have read it, and I understand its content and
significance.
MEDICAL ALERTS -
Severe allergies / life threatening conditions / chronic illnesses
Signature of Parent/Guardian(For participant less than 18 years of age)
Date
Signature of Participant(For participant 18 years of age or older)
Date
Witness Signature(an adult able to verify the above signatures)
Date
WSU Football Camp
Participant Health Form
Mail this form to address below:
Football Office
BAC 102
P O Box 641602
Pullman, WA 99164-1602
Participant Name: _______________________________________________
First
Middle
Last
Attendance date(s):_______________________
Male
Female Birth Date ___________ Age on arrival at camp: ______
(Month / Day / Year)
To Parent(s)/Guardian(s): Please keep a copy for your records.
Participant Home Address: ___________________________________________________________________________________
Street Address
City
State
Zip Code
Parent/guardian with residential placement and/or decision-making authority in the event of illness or injury:
Name:___________________________________________________________
Preferred Phones: (______) _______________
(______) ______________
Relationship
to Participant: _____________________
Email: ________________________________
Home Address:
________________________________________________________________________________________________________
(If different from above)
Street Address
City
State
Zip Code
Second parent/guardian with legal responsibility/authority to be contacted in case of illness or injury, if available:
Name:___________________________________________________________
Preferred Phones: (______) _________________
Relationship
to Participant: _____________________
(______) _______________
Additional emergency contact (optional):
Name:___________________________________________________________
Preferred Phones: (______) _________________
Relationship
to Participant: _____________________
(______) _______________
Pre-Existing Medical Conditions:
Has the camp participant had, or currently have, any of the following?
Concussions Y N
Asthma Y N
Heat Illness Y N
Epilepsy Y N
Surgery Y N
Diabetes Y N
Current Orthopedic Injury Y N
Heart Condition (ie. HCM) Y N
Sickle Cell / Trait Y N
ADD / ADHD Y N
Other Y N
If you answered ‘yes’ to any of the above questions please explain in the “General Health Information” section or attach additional
information.
Immunizations:
My child is up-to-date on his/her immunizations and tetanus shots as required by Washington State law.
My child has an immunization exemption on file with his/her school. I understand and accept the risks to my child from
not being fully immunized.
General Health Information:
NOTE: It is strongly recommended that parents/legal guardians consult a physician prior to allowing their child to participate
in physical activity.
Are there any medical concerns which the camp staff should be aware of? Attach additional information if needed.
Allergies:
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 detail, what the participant is allergic to, the reaction seen & any preventive or responsive
measures utilized (ie. medications). Attach additional forms if necessary.
Disability:
Does the participant require reasonable accommodation for a disability in order to access or be part of the activities?
Medication – Mini Camp/Kicking Showcase:
Unfortunately, we will be unable to administer medication to children participating in day camps. If your child requires a dosage during
camp hours, please make appropriate arrangements. Medication is any substance a person takes to maintain and/or improve their
health. This includes vitamins & natural remedies.
This participant will not take any daily medications while attending the activities.
Medication – Overnight Campers:
Medication is any substance a person takes to maintain and/or improve their health. This includes all prescription medication, as well
as all over-the counter drugs that are potentially hazardous if misused (e.g., Tylenol, aspirin, cough medicine, cold tablets, vitamins &
natural remedies. All medications must be in their original containers. Prescriptions must have the child’s name and how the
medication should be given printed on the prescription container. Please send only those medications that are necessary.
Participants are required to turn medications into staff upon arrival.
This participant will not take any daily medications while attending the activities.
This participant will be self-administering the following daily medication(s) while attending the activities under staff
1
supervision.
Name of
medication
Date
started
Reason for Taking
When it is given
Amount or dose
given
How it is given
Breakfast
Lunch
Dinner
Other time:
___________
Breakfast
Lunch
Dinner
Other time:
___________
Breakfast
Lunch
Dinner
Other time:
___________
Comments
Health History Verification:
This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person
described has permission to participate in all program activities except as set forth by me and/or an examining physician. If
you fail to advise WSU of a medical condition, risks to your child 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 child’s health record from providers who treat my
child and these providers may talk with the program’s staff about my child’s health status.
Signature of Primary Residential Parent: _________________________________________________
Date: _______________
Parent/Guardian (please print name): ___________________________________________________
Relationship to Participant: ___________________________
Parent/Guardians: Keep a copy for your records.
1
Note: These provisions regarding administration of medication shall not abrogate minors’ rights to provide their own consent to certain services under
Washington law.
ASSUMPTION OF RISK
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 to my child 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 the WSU Football 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 the WSU Football 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.
EMERGENCY MEDICAL RELEASE
In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU)
authorized agents including WSU Football Camp staff to be an emergency; I authorize WSU and its authorized agents to
obtain emergency medical care for my child. 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 child’s health record from providers who treat my child and these
providers may talk with the program’s staff about my child’s health status.
I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and
the staff of WSU Football Camp from decisions to seek emergency treatment
RELEASE OF LIABILITY
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 of my child, as a result of or connected with participation in the above
event. My child’s 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 sign it
freely and voluntarily.
Signature of Parent / Guardian: _____________________________________________
Date: _____________
Parent / Guardian (please print): ____________________________________________
Witness Signature: _______________________________________________________
Witness Name (please print): _______________________________________________
Date: _____________