2018 medical release form
2018 MEDICAL RELEASE FORM **Complete and return this form with camp application** Consent to Medical Treatment & Release of Liability (Read this before signing below) Parent/Guardian shall hereby release, hold harmless and indemnify the Florida Gulf Coast University Board of Trustees, and Florida Gulf Coast University and its officers, employees and agents, for and against any and all liability claims, charges, damages, demands, expenses, fees, fines, penalties, losses, suits, proceedings, actions, and costs thereof (including attorney fees and court costs for all actions and appeals therefrom), judgments, injuries, damages or liabilities, in law or in equity, of any kind and nature resulting from or arising out of an illness or injury related to my child’s acts or omissions while a participant in the 2018 FGCU Volleyball Camps.
Parent/Guardian Signature
Date Signed
Campers Name (Print) Medical Insurance Company Name Policy Number
Group Number
Insurance Company Phone Number
Insured’s Name
www.azulbeauty.com Office: 239-415-7576
I HAVE READ THIS WAIVER OF LIABILITY AND FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Sponsored By:
It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the member of my family and my spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue the above named releasee. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Florida. In signing this release, I acknowledge and represent that I have read and understand it and sign it voluntarily; I am at least eighteen (18) years of age and fully competent; and I execute this release for full, adequate and complete consideration fully intending to be bound by the same.
FLORIDA GULF COAST UNIVERSITY 10501 FGCU BOULEVARD SOUTH FORT MYERS, FL 33965-6565
During the period of the camp, I hereby give permission for the staff of Florida Gulf Coast University or this camp to administer appropriate medical attention to me/my child in the event of an accident, illness or injury. I will be responsible for any and all costs of medical coverage and treatment provided not covered by insurance.
2016 FGCU SUMMER VOLLEYBALL CAMPS
To the best of my knowledge, I/my child am/is in good physical condition and I am not aware of any physical infirmity which would place me/my child at risk to participate in any way with camp activities. I am fully aware of risks and hazards connected with the camp. I voluntarily assume full responsibility for any risk of loss, property damage, or personal injury, including death, that may be sustained by me/my child, or any loss or damage to property owned by me/my child as a result of being engaged in the camp’s activities, whether caused by the negligence of the releasee or otherwise. I further here-by agree to indemnify and hold harmless the releasee from any loss, liability, damage, or cost, including court costs and attorney’s fees, that may accrue related to me/my child’s participation in this camp, whether caused by the negligence of the releasee or otherwise.
CAMP DETAILS ATTACKING CAMP
ATTACKING DAY CAMP (JULY 9TH, 2018) (ADC) Deposit: $100.00 | Commuter: $135.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 9th) | Check Out: 5:00PM (July 9th) **Lunch NOT included** ATTACKING/SERVING DAY CAMP (JULY 23RD, 2018) (ASDC) Deposit: $100.00 (Non-Refundable) | Commuter: $135.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 23rd) | Check Out: 5:00PM (July 23rd) **Lunch NOT included** | **Times are subject to change** 64 Spots (open to all based on availability)
BALL HANDLING/1ST CONTACT CAMP
• There will be two different ways to sign up for camps. • Sign up online at: www.FGCUVolleyballCamps.com. • Fill out the application & send it in along with a deposit.
Contact Danny Mahy in the FGCU Volleyball Office of at 239.590.7223 or 786.554.9848.
CAMPERS SHOULD BRING
This year only lunch and dinner will be provided, so please bring breakfast snacks for your dorm rooms. All rooms are equipped with a full kitchen.
TEAM CAMP
OVERNIGHT TEAM CAMP (JULY 25TH – 27TH, 2018) (TC) Deposit: $200.00 | Commuter: $315.00 | Resident: $370.00 Check In: 1:30PM – 2:30PM (July 25th) Check Out: 3:00PM - 4:00PM (July 27th) 15 Teams (8 Players Per Team)
*Note: each individual signing up must be affiliated with a registered team.
PARENT/GUARDIAN INFORMATION
Name(s) Home Phone Cell Phone Email Address
CAMPERS ARE EXPECTED TO: Act with respect for themselves, other campers, staff, and the campus of Florida Gulf Coast University. Campers who cannot behave in a mature manner could be expelled from camp without a refund.
CAMP LOCATION All check-in’s and outs, camps and sessions will be held on the campus of Florida Gulf Coast University at Alico Arena. All campers will be staying at the on campus housing called North Lake Village. All camp times are subject to change.
SPACE IN EACH CAMP IS LIMITED!!!
ADC
ASDC
BHFC
AS1
AS2 AS3 TC COMMUTER
RESIDENT
CIRCLE SHIRT SIZE
FOOD Artichoke & Company, a delicatessen and full service catering company, will provide all lunches and dinners during the camps. For further information please check out their website or contact Brian Gorman at the number below.
SMALL
MEDIUM
LARGE
X-LARGE
MAKE ROOMATE REQUESTS BELOW | UP TO 4 IN A ROOM
Website: www.ArtichokeAndCompany.com Phone: 239.263.6979
CAMP STAFF
Team Camp Description This camp is tailored toward high school programs looking for an opportunity to train as a team in advance of their season. There will be an emphasis on team systems and concepts while also incorporating individual skills training within the sessions. With feedback from each team’s respective coaches (who are encouraged to attend) we will personalize the training focus to reflect the needs of each group. The environment is fast paced, repetition intensive, and constructive. Camp will conclude with tournament play. Campers must bring their own breakfast foods. Lunch and Dinner will be served at Alico Arena in the VIP Room.
Name Address City State Zip Grade Entering Fall 2018 Age School Club Team
EMERGENCIES
ALL SKILLS CAMPS
OVERNIGHT ALL SKILLS CAMP (JULY 19TH – 21ST, 2018) (AS3) Deposit: $200.00 | Commuter: $315.00 | Resident: $370.00 Blue Group Ages: 9-13 | Green Group Ages: 14-17 Blue Group Check In: 11:00AM – 12:00PM (July 19th) Green Group Check In: 1:00PM – 2:00PM (July 19th) Blue Group Check Out: 3:00PM - 4:00PM (July 21st) Green Group Check Out: 5:00PM - 6:00PM (July 21st)
CAMPER INFORMATION
*DEPOSIT IS NON-REFUNDABLE*
Appropriate shoes and volleyball training clothes; knee pads. Also bring all your things that you will need to sleep over in the dorm rooms, including bedding for a twin bed.
ALL SKILLS DAY CAMP (JULY 16TH – 17TH, 2018) (AS2) Deposit: $200.00 | Commuter: $265.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 16th) Check Out: 4:30PM (July 17th) **Lunch NOT included**
CAMP APPLICATION
Please do not delay to register. Sessions are filled on a first-come, first-served basis.
BALL HANDLING/1ST CONTACT DAY CAMP (JULY 10TH, 2018) (BHFC) Deposit: $100.00 | Commuter: $135.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 10th) | Check Out: 5:00PM (July 10th) **Lunch NOT included**
OVERNIGHT ALL SKILLS CAMP (JULY 12TH – 14TH, 2018) (AS1) Deposit: $200.00 | Commuter: $315.00 | Resident: $370.00 Blue Group Ages: 9-13 | Green Group Ages: 14-17 Blue Group Check In: 11:00AM – 12:00PM (July 12th) Green Group Check In: 1:00PM – 2:00PM (July 12th) Blue Group Check Out: 3:00PM - 4:00PM (July 14th) Green Group Check Out: 5:00PM - 6:00PM (July 14th)
FGCU VOLLEYBALL
SPACE IN EACH CAMP IS LIMITED!!!
MATT BOTSFORD
• Current FGCU head volleyball coach for both indoor and beach • Former asst. for Colorado State, Notre Dame, and University of Miami • Helped lead CSU to school record 27 straight wins (2013) and fifth straight conference championship • Won 2012 Swedish Elite Series Championship as head coach for Lindesberg Volley • Former professional volleyball player before transitioning into coaching
MAKE CHECKS PAYABLE TO: Florida Gulf Coast Volleyball, LLC
MAIL APPLICATION TO:
DANNY MAHY
Florida Gulf Coast University 10501 FGCU Blvd. South Fort Myers, FL 33965 Attn: Danny Mahy
REGISTER ONLINE FGCUVolleyballCamps.com
Parent/Guardian Signature
Date Signed
Campers Name (Print) Medical Insurance Company Name Policy Number
Group Number
Insurance Company Phone Number
Insured’s Name
www.azulbeauty.com Office: 239-415-7576
I HAVE READ THIS WAIVER OF LIABILITY AND FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Sponsored By:
It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the member of my family and my spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue the above named releasee. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Florida. In signing this release, I acknowledge and represent that I have read and understand it and sign it voluntarily; I am at least eighteen (18) years of age and fully competent; and I execute this release for full, adequate and complete consideration fully intending to be bound by the same.
FLORIDA GULF COAST UNIVERSITY 10501 FGCU BOULEVARD SOUTH FORT MYERS, FL 33965-6565
During the period of the camp, I hereby give permission for the staff of Florida Gulf Coast University or this camp to administer appropriate medical attention to me/my child in the event of an accident, illness or injury. I will be responsible for any and all costs of medical coverage and treatment provided not covered by insurance.
2016 FGCU SUMMER VOLLEYBALL CAMPS
To the best of my knowledge, I/my child am/is in good physical condition and I am not aware of any physical infirmity which would place me/my child at risk to participate in any way with camp activities. I am fully aware of risks and hazards connected with the camp. I voluntarily assume full responsibility for any risk of loss, property damage, or personal injury, including death, that may be sustained by me/my child, or any loss or damage to property owned by me/my child as a result of being engaged in the camp’s activities, whether caused by the negligence of the releasee or otherwise. I further here-by agree to indemnify and hold harmless the releasee from any loss, liability, damage, or cost, including court costs and attorney’s fees, that may accrue related to me/my child’s participation in this camp, whether caused by the negligence of the releasee or otherwise.
CAMP DETAILS ATTACKING CAMP
ATTACKING DAY CAMP (JULY 9TH, 2018) (ADC) Deposit: $100.00 | Commuter: $135.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 9th) | Check Out: 5:00PM (July 9th) **Lunch NOT included** ATTACKING/SERVING DAY CAMP (JULY 23RD, 2018) (ASDC) Deposit: $100.00 (Non-Refundable) | Commuter: $135.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 23rd) | Check Out: 5:00PM (July 23rd) **Lunch NOT included** | **Times are subject to change** 64 Spots (open to all based on availability)
BALL HANDLING/1ST CONTACT CAMP
• There will be two different ways to sign up for camps. • Sign up online at: www.FGCUVolleyballCamps.com. • Fill out the application & send it in along with a deposit.
Contact Danny Mahy in the FGCU Volleyball Office of at 239.590.7223 or 786.554.9848.
CAMPERS SHOULD BRING
This year only lunch and dinner will be provided, so please bring breakfast snacks for your dorm rooms. All rooms are equipped with a full kitchen.
TEAM CAMP
OVERNIGHT TEAM CAMP (JULY 25TH – 27TH, 2018) (TC) Deposit: $200.00 | Commuter: $315.00 | Resident: $370.00 Check In: 1:30PM – 2:30PM (July 25th) Check Out: 3:00PM - 4:00PM (July 27th) 15 Teams (8 Players Per Team)
*Note: each individual signing up must be affiliated with a registered team.
PARENT/GUARDIAN INFORMATION
Name(s) Home Phone Cell Phone Email Address
CAMPERS ARE EXPECTED TO: Act with respect for themselves, other campers, staff, and the campus of Florida Gulf Coast University. Campers who cannot behave in a mature manner could be expelled from camp without a refund.
CAMP LOCATION All check-in’s and outs, camps and sessions will be held on the campus of Florida Gulf Coast University at Alico Arena. All campers will be staying at the on campus housing called North Lake Village. All camp times are subject to change.
SPACE IN EACH CAMP IS LIMITED!!!
ADC
ASDC
BHFC
AS1
AS2 AS3 TC COMMUTER
RESIDENT
CIRCLE SHIRT SIZE
FOOD Artichoke & Company, a delicatessen and full service catering company, will provide all lunches and dinners during the camps. For further information please check out their website or contact Brian Gorman at the number below.
SMALL
MEDIUM
LARGE
X-LARGE
MAKE ROOMATE REQUESTS BELOW | UP TO 4 IN A ROOM
Website: www.ArtichokeAndCompany.com Phone: 239.263.6979
CAMP STAFF
Team Camp Description This camp is tailored toward high school programs looking for an opportunity to train as a team in advance of their season. There will be an emphasis on team systems and concepts while also incorporating individual skills training within the sessions. With feedback from each team’s respective coaches (who are encouraged to attend) we will personalize the training focus to reflect the needs of each group. The environment is fast paced, repetition intensive, and constructive. Camp will conclude with tournament play. Campers must bring their own breakfast foods. Lunch and Dinner will be served at Alico Arena in the VIP Room.
Name Address City State Zip Grade Entering Fall 2018 Age School Club Team
EMERGENCIES
ALL SKILLS CAMPS
OVERNIGHT ALL SKILLS CAMP (JULY 19TH – 21ST, 2018) (AS3) Deposit: $200.00 | Commuter: $315.00 | Resident: $370.00 Blue Group Ages: 9-13 | Green Group Ages: 14-17 Blue Group Check In: 11:00AM – 12:00PM (July 19th) Green Group Check In: 1:00PM – 2:00PM (July 19th) Blue Group Check Out: 3:00PM - 4:00PM (July 21st) Green Group Check Out: 5:00PM - 6:00PM (July 21st)
CAMPER INFORMATION
*DEPOSIT IS NON-REFUNDABLE*
Appropriate shoes and volleyball training clothes; knee pads. Also bring all your things that you will need to sleep over in the dorm rooms, including bedding for a twin bed.
ALL SKILLS DAY CAMP (JULY 16TH – 17TH, 2018) (AS2) Deposit: $200.00 | Commuter: $265.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 16th) Check Out: 4:30PM (July 17th) **Lunch NOT included**
CAMP APPLICATION
Please do not delay to register. Sessions are filled on a first-come, first-served basis.
BALL HANDLING/1ST CONTACT DAY CAMP (JULY 10TH, 2018) (BHFC) Deposit: $100.00 | Commuter: $135.00 | Ages: 8-18 Check In: 9:00AM – 10:00AM (July 10th) | Check Out: 5:00PM (July 10th) **Lunch NOT included**
OVERNIGHT ALL SKILLS CAMP (JULY 12TH – 14TH, 2018) (AS1) Deposit: $200.00 | Commuter: $315.00 | Resident: $370.00 Blue Group Ages: 9-13 | Green Group Ages: 14-17 Blue Group Check In: 11:00AM – 12:00PM (July 12th) Green Group Check In: 1:00PM – 2:00PM (July 12th) Blue Group Check Out: 3:00PM - 4:00PM (July 14th) Green Group Check Out: 5:00PM - 6:00PM (July 14th)
FGCU VOLLEYBALL
SPACE IN EACH CAMP IS LIMITED!!!
MATT BOTSFORD
• Current FGCU head volleyball coach for both indoor and beach • Former asst. for Colorado State, Notre Dame, and University of Miami • Helped lead CSU to school record 27 straight wins (2013) and fifth straight conference championship • Won 2012 Swedish Elite Series Championship as head coach for Lindesberg Volley • Former professional volleyball player before transitioning into coaching
MAKE CHECKS PAYABLE TO: Florida Gulf Coast Volleyball, LLC
MAIL APPLICATION TO:
DANNY MAHY
Florida Gulf Coast University 10501 FGCU Blvd. South Fort Myers, FL 33965 Attn: Danny Mahy
REGISTER ONLINE FGCUVolleyballCamps.com
