medical waivers & insurance forms ty · 2019-06-05 · pole vault, shot put, and discus....

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Black Hills State University Yellow Jacket Track and Field Camp Schedule Sprints/Hurdles—June 17th LJ/TJ—June 18th Pole Vault/High Jump—June 20th Throws—June 21st Each day will consist of a morning session (10:00am- 12:00pm) and an afternoon session (1:00pm-3:00pm) Check-In Check-in will be held in the lobby of the Donald E. Young Center at 9:30am each day. Camp Gear All campers need to bring appropriate training gear, including spikes, pole vault poles, shots/discs, running and/or throwing shoes and swim suits. Sunscreen and a water bole are encouraged. Extra spending money for vending and/or snacks may be helpful also. Facilities We will utilize a combination of both our indoor and outdoor facilities to give our campers the best experience possible. Meals Lunch will be provided for all campers between morning and afternoon sessions. Insurance Each camper must be covered by their own accident and medical insurance. Refunds Black Hills State University allows no refunds due to personal injury, any conflicting camps or tournaments, vacations, etc. Registration Pre-registration by June 14, 2019 is preferred - but not required. Campers can register by mail or online at www.YellowJacketSportsCamps.com. Please make checks payable to BHSU Track & Field. Camp is directed by BHSU Coaches and members of the Yellow Jacket Track and Field Team Camp Information Medical Waivers & Insurance Forms Black Hills State University Parents or Guardians Agreement of Waiver of Liability, Indemnification and Medical Release (For use by adults during special events and activities if the participant is under 18 years of age.) Said undersigned parent and natural guardian or legal guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees on behalf of the participant and his/her executors, administrators, heirs, next of kin, successors, and assigns, to: a. waive, release, and discharge from any and all liability for participants death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to participant and his/her estate, the State of South Dakota, and its officers, agents and employees; and b. indemnify and hold harmless the State of South Dakota, and its officers, agents and employees from and against any and all liabilities and claims made by other individuals or entities as a result of participants participation or actions during this activity or event. The undersigned further consents to and authorizes medical treatment to the participant, which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release and waiver shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I, the undersigned, acknowledge that I have read and understand the above release. Parent/Legal Guardian Name: _____________________ Signature _______________________________________ Insurance Company: _____________________________ Insurance Policy Number: ________________________ Date____________________________________________ *Insurance is required to participate in camp.

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Camp Schedule

Sprints/Hurdles—June 17th

LJ/TJ—June 18th

Pole Vault/High Jump—June 20th

Throws—June 21st

Each day will consist of a morning session (10:00am-

12:00pm) and an afternoon session (1:00pm-3:00pm)

Check-In Check-in will be held in the lobby of the Donald E. Young

Center at 9:30am each day.

Camp Gear

All campers need to bring appropriate training gear, including

spikes, pole vault poles, shots/discs, running and/or throwing

shoes and swim suits. Sunscreen and a water bottle are

encouraged. Extra spending money for vending and/or snacks

may be helpful also.

Facilities We will utilize a combination of both our indoor and outdoor

facilities to give our campers the best experience possible.

Meals

Lunch will be provided for all campers between morning and

afternoon sessions.

Insurance

Each camper must be covered by their own accident and

medical insurance.

Refunds Black Hills State University allows no refunds due to personal

injury, any conflicting camps or tournaments, vacations, etc.

Registration

Pre-registration by June 14, 2019 is preferred - but not

required. Campers can register by mail or online at

www.YellowJacketSportsCamps.com. Please make checks

payable to BHSU Track & Field.

Camp is directed by BHSU Coaches and members of the

Yellow Jacket Track and Field Team

Camp Information Medical Waivers & Insurance Forms

Black Hills State University Parents or Guardians

Agreement of Waiver of Liability, Indemnification

and Medical Release (For use by adults during special events and activities if the participant is under 18 years of age.) Said undersigned parent and natural guardian or legal guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees on behalf of the participant and his/her executors, administrators, heirs, next of kin, successors, and assigns, to: a. waive, release, and discharge from any and all

liability for participant’s death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to participant and his/her estate, the State of South Dakota, and its officers, agents and employees; and

b. indemnify and hold harmless the State of South

Dakota, and its officers, agents and employees from and against any and all liabilities and claims made by other individuals or entities as a result of participant’s participation or actions during this activity or event.

The undersigned further consents to and authorizes medical treatment to the participant, which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release and waiver shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I, the undersigned, acknowledge that I have read and understand the above release.

Parent/Legal Guardian Name: _____________________

Signature _______________________________________

Insurance Company: _____________________________

Insurance Policy Number: ________________________

Date____________________________________________

*Insurance is required to participate in camp.

2019 Track and Field Camp Information

Seth Mischke Head Track & Field Coach

21 Rocky Mountain Athletic

Conference champions, 100 All-

Conference honorees, 30 All-American

honors, and two National Champions.

Christopher Fields Assistant Track & Field Coach

Sam Johnson Head Track & Field Coach

Johnson is in his seventh year as the

head coach for the Golden Bears. In

his tenure, the program has set 52

school records and boasts 18 All-

NSIC selections and 12 national

qualifying marks.

Track & Field Camp

Track & Field camp is open to all athletes entering 7th-

12th grades. Each athlete will receive specialized

training in one or more of the following event areas:

sprints, hurdles, long jump, triple jump, high jump,

pole vault, shot put, and discus. Workouts will be

structured to improve technique in each specific event

thru a combination of training, demonstrations, and

drills. There may also be classroom sessions that will

enhance the camper’s technical understanding of the

different events;. Other sessions may include

flexibility, plyometric and strength training.

Camp Costs include coaching, meals, and a t-shirt:

Camper fees $80 per/day

*If a camper attends more than one of the day camps

the price will be reduced to $60 for each additional day.

Our highly qualified staff is capable of teaching the

beginner, intermediate and the most veteran of

performers—and all levels are welcome.

*These are commuter camps and overnight lodging

will not be provided.

Payment Information

BHSU Track & Field

1200 University Unit 9410

Spearfish, SD 57799-9410

BHSU Track & Field Camp

General Information

Camper’s Name:_________________________________________________

Address: ______________________________________________________

City: _________________________________ State:_____ Zip: ___________

Email:___________________________________________________________

Parent’s Name:___________________________________________________

Phone: C:__________________________W:___________________________

Grade Entering Fall 2019:___________DOB:__________________________

T&F Event(s):____________________________________________________

Camp Information

Track and Field Camp—June 17, 18, 20, 21. All camps

are from 10am-3pm.

*Please circle intended dates:

June 17

June 18

June 20

June 21

We look forward to seeing

you at the BHSU track and field camp!

Registration

Camp Contact Information Camp Coordinator: Seth Mischke

Phone: (605) 642-6041

Email: [email protected]

Payment Information for Internal Use:

Payment Type_________ Amount ______

Check # ______________ Date ________