Black Hills State University
Medical Waivers & Insurance Forms
Insurance Company: __________________________ Insurance Policy Number: ______________________ Date_______________________________________
T Shirt
Signature ____________________________________
You will be given a choice when you arrive
Parent/Legal Guardian Name: ___________________
Refunds Black Hills State University allows no refunds due to personal injury, any conflicting camps or tournaments, vacations, etc.
I, the undersigned, acknowledge that I have read and understand the above release.
Camper’s name:__________________________________________________________________
This release and waiver shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
School:_______________________________________________________Grad Year:_________
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.
Address:_________________________________________City:_________St:______Zip:_______
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.
Email address:____________________________ Phone:_________________________________
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
Payment Information Black Hills State University Soccer Camp 1200 University Unit 9414 Spearfish, SD 57799-9410 Phone: (262) 949-1571 Fax: (605) 642-6539 Email: [email protected]
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:
Mother’s name:_________________________________ Cell Phone:________________________
(For use by adults during special events and activities if the participant is under 18 years of age.)
Father’s name: __________________________________Cell Phone:________________________
Camp:
SD ID Camp
$150
Black Hills State University Parents or Guardians Agreement of Waiver of Liability, Indemnification and Medical Release
Walk-Up Camp Registration
Black Hills State
University
ID Camp August 18—19 2017
Online Registration
BHSU ID Camp August 18—19, 2017 Schedule: Friday 8/18 9:00 AM Sign in 9:30 AM Technical session 11:00 AM Finish 12:00 PM Lunch/ Team Builder/Meet Team 1:00 PM Leave for creek 3:00 PM Return 7:00 PM Full practice Saturday 8/19 9:00 AM Breakfast and Hike 12:00 PM Lunch 3:00 PM Full practice BHSU soccer philosophy is that everyone still can develop, we will help you develop by getting you on the ball and teaching you the essentials we believe you need to succeed. We work your individual position skills, to help fit into a whole team concept!
BHSU soccer is entering an exciting time— come be a part of the Yellow Jackets history. Camp Contact Information Angelina Delgado: Camp Coordinator Phone: (262) 949-1571 Email: [email protected]
Registration: Please register Online by August 16th. Walkup registrations will be limited to 10 and only on the day of camp. Camp Gear: All campers will be encouraged to bring and wear suitable soccer attire. This includes cleats/turf shoes, shin guards, and other suitable soccer attire. Bring a water bottle. Bring swimming gear (we have certified life guards) Camp Directions: Camp will be held at Ronnie Thiesz Field 1468 College Lane, Spearfish, SD 57783 Meals: Will be provided with this camp Housing: No housing will be provided..
Insurance Company: __________________________ Insurance Policy Number: ______________________ Date_______________________________________
T Shirt
Signature ____________________________________
You will be given a choice when you arrive
Parent/Legal Guardian Name: ___________________
Refunds Black Hills State University allows no refunds due to personal injury, any conflicting camps or tournaments, vacations, etc.
I, the undersigned, acknowledge that I have read and understand the above release.
Camper’s name:__________________________________________________________________
This release and waiver shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
School:_______________________________________________________Grad Year:_________
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.
Address:_________________________________________City:_________St:______Zip:_______
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.
Email address:____________________________ Phone:_________________________________
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
Payment Information Black Hills State University Soccer Camp 1200 University Unit 9414 Spearfish, SD 57799-9410 Phone: (262) 949-1571 Fax: (605) 642-6539 Email: [email protected]
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:
Mother’s name:_________________________________ Cell Phone:________________________
(For use by adults during special events and activities if the participant is under 18 years of age.)
Father’s name: __________________________________Cell Phone:________________________
Camp:
SD ID Camp
$150
Black Hills State University Parents or Guardians Agreement of Waiver of Liability, Indemnification and Medical Release
Walk-Up Camp Registration
Black Hills State
University
ID Camp August 18—19 2017
Online Registration
BHSU ID Camp August 18—19, 2017 Schedule: Friday 8/18 9:00 AM Sign in 9:30 AM Technical session 11:00 AM Finish 12:00 PM Lunch/ Team Builder/Meet Team 1:00 PM Leave for creek 3:00 PM Return 7:00 PM Full practice Saturday 8/19 9:00 AM Breakfast and Hike 12:00 PM Lunch 3:00 PM Full practice BHSU soccer philosophy is that everyone still can develop, we will help you develop by getting you on the ball and teaching you the essentials we believe you need to succeed. We work your individual position skills, to help fit into a whole team concept!
BHSU soccer is entering an exciting time— come be a part of the Yellow Jackets history. Camp Contact Information Angelina Delgado: Camp Coordinator Phone: (262) 949-1571 Email: [email protected]
Registration: Please register Online by August 16th. Walkup registrations will be limited to 10 and only on the day of camp. Camp Gear: All campers will be encouraged to bring and wear suitable soccer attire. This includes cleats/turf shoes, shin guards, and other suitable soccer attire. Bring a water bottle. Bring swimming gear (we have certified life guards) Camp Directions: Camp will be held at Ronnie Thiesz Field 1468 College Lane, Spearfish, SD 57783 Meals: Will be provided with this camp Housing: No housing will be provided..
