DALTON STATE
2015 MEDICAL RELEASE FORM
Consent to Medical Treatment & Release of Liability (Read this before signing below)
PLACE STAMP HERE
**Complete and return this form with camp application**
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 Georgia. 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. I HAVE READ THIS WAIVER OF LIABILITY AND FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT
Parent/Guardian Signature
Campers Name (PRINT)
Medical Insurance Company Name
Dalton State College Athleic Department—Volleyball 4567 Main Street Raleigh, 650 College Drive Dalton Ga, 30720+NC 02134
In consideration of being allowed to participate in this camp, related events, and activities, I hereby release, waive, discharge, and covenant not to sue Dalton State College, this camp, and Its directors and employees (hereinafter referred to as releasee) from any and all liability, claims, demands, or course of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me/my child, or to any property belonging to me/my child, whether caused by the negligence of the releasee, or otherwise, while participating in the camp, or while in, on or upon the premises where the camp is being conducted. 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 release 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. During the period of the camp, I hereby give permission for the staff of Dalton State College 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.
2015
DALTON STATE
Camp Details All Skills We Be Covered Players will be grouped by skill level at which point high repetition training will guide our sessions. Our emphasis is on building a strong foundation for each player and increasing skill development and growth. DSC coaches will cover all phases of the game and position specific opportunities will be presented within each session.
Camp Pricing
many sessions you feel your team needs.
Team Component This part of camp will combine skill sessions, wash drill sessions, and team competition. We encourage high school coaches to let us know what they would like to emphasize during this time. The format will focus on skills during the first skills sessions and then work our way to real match play. Systems, mental approaches, and tactics will be also be taught.
CAMPERS SHOULD BRING
Address ________________________________ ________________________________________ City_________________ State ______ Zip____
For every session it is $25.00 per athlete.
Grade Entering Fall 2015 Age ___________
We recommend 3 - 6 sessions depending on the level of experience your players have.
School _________________________________ Club Team _____________________________ PARENT/GUARDIAN INFORMATION Name(s) _______________________________
Camp Staff Bruna Langner Entering her 3rd year as Dalton State College head coach,
Southern States Athletic Conference Player of the Year
________________________________________ Home Phone ___________________________
Cell Phone _____________________________ Email Address _________________________
2006 Region NAIA Player of the Year
All camps and sessions will be held at the location of the schools choice. This means that we will be coming to YOU!
Courtney Wilson
Entering her 2nd year as assistant coach for the Lady Roadrunners.
Former player for MTSU and Lee University.
Helped DSC to their 3rd place finish in the SSAC last year.
If you have an questions or would like
[email protected]
Name __________________________________
minimum)
$75.00)
CAMP LOCATION
Coach Langner at::
Each session is 3hrs ( there is a 2 session
(Ex. 2 sessions = $50.00 or 3 sessions =
Appropriate shoes and volleyball training clothes; knee pads. Please bring water or Gatorade so that we can use our time efficiently.
to schedule your camp please email
The price of camp is based on how
DSC Camp Application
Circle Shirt Size Below YOUTH S
ADULT S
YOUTH M
ADULT M
YOUTH L
ADULT L
YOUTH XL
ADULT XL
Consent to Medical Treatment & Release of Liability (Read this before signing below)
PLACE STAMP HERE
**Complete and return this form with camp application**
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 Georgia. 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. I HAVE READ THIS WAIVER OF LIABILITY AND FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT
Parent/Guardian Signature
Campers Name (PRINT)
Medical Insurance Company Name
Dalton State College Athleic Department—Volleyball 4567 Main Street Raleigh, 650 College Drive Dalton Ga, 30720+NC 02134
In consideration of being allowed to participate in this camp, related events, and activities, I hereby release, waive, discharge, and covenant not to sue Dalton State College, this camp, and Its directors and employees (hereinafter referred to as releasee) from any and all liability, claims, demands, or course of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me/my child, or to any property belonging to me/my child, whether caused by the negligence of the releasee, or otherwise, while participating in the camp, or while in, on or upon the premises where the camp is being conducted. 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 release 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. During the period of the camp, I hereby give permission for the staff of Dalton State College 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.
2015
DALTON STATE
Camp Details All Skills We Be Covered Players will be grouped by skill level at which point high repetition training will guide our sessions. Our emphasis is on building a strong foundation for each player and increasing skill development and growth. DSC coaches will cover all phases of the game and position specific opportunities will be presented within each session.
Camp Pricing
many sessions you feel your team needs.
Team Component This part of camp will combine skill sessions, wash drill sessions, and team competition. We encourage high school coaches to let us know what they would like to emphasize during this time. The format will focus on skills during the first skills sessions and then work our way to real match play. Systems, mental approaches, and tactics will be also be taught.
CAMPERS SHOULD BRING
Address ________________________________ ________________________________________ City_________________ State ______ Zip____
For every session it is $25.00 per athlete.
Grade Entering Fall 2015 Age ___________
We recommend 3 - 6 sessions depending on the level of experience your players have.
School _________________________________ Club Team _____________________________ PARENT/GUARDIAN INFORMATION Name(s) _______________________________
Camp Staff Bruna Langner Entering her 3rd year as Dalton State College head coach,
Southern States Athletic Conference Player of the Year
________________________________________ Home Phone ___________________________
Cell Phone _____________________________ Email Address _________________________
2006 Region NAIA Player of the Year
All camps and sessions will be held at the location of the schools choice. This means that we will be coming to YOU!
Courtney Wilson
Entering her 2nd year as assistant coach for the Lady Roadrunners.
Former player for MTSU and Lee University.
Helped DSC to their 3rd place finish in the SSAC last year.
If you have an questions or would like
[email protected]
Name __________________________________
minimum)
$75.00)
CAMP LOCATION
Coach Langner at::
Each session is 3hrs ( there is a 2 session
(Ex. 2 sessions = $50.00 or 3 sessions =
Appropriate shoes and volleyball training clothes; knee pads. Please bring water or Gatorade so that we can use our time efficiently.
to schedule your camp please email
The price of camp is based on how
DSC Camp Application
Circle Shirt Size Below YOUTH S
ADULT S
YOUTH M
ADULT M
YOUTH L
ADULT L
YOUTH XL
ADULT XL
