Cross Country Camp
Please Detach And Return
2015 CSC Cross Country Camp Authorization and Release Form Note: In order for your child to participate in the 2015 Chadron State Cross Country Camp on June 28-30, this form must be completed, signed, and returned to the College prior to the first day of camp.
Child’s Printed Name
Child’s Date of Birth
Authorization
Key Offerings An educational experience regarding the sport of cross country with high level training, guest speakers, and the Chadron State coaching staff.
I authorize and give my consent for any licensed medical provider or athletic trainer to provide medical treatment, emergency services, or assistance to my child related to his/her participation in the 2015 Chadron State Cross Country Camp. I agree to assume all costs related to such treatment, services, or assistance.
As we begin to build our tradition here at Chadron State College, let us help you start or continue yours.
Insurance Company
Contact Us/Mail Form to:
Policy Number
Release I give permission for my child (identified above) to participate in the 2015 Chadron State Cross Country Camp. I assume all risks of accident or injury that may result from his/her participation in this activity. I release the Nebraska State Colleges, the Board of Trustees of the Nebraska State College, Chadron State College, and all officers, employees, agents, volunteers, and participants from liability including, but not limited to, legal claims and suits for any injury, damage or loss (personal or property) resulting from his/her participation in this activity.
Parent/Guardian Printed Name
Parent/Guardian Signature
Date
Chadron State College Cross Country Attn. to: Brian Medigovich 1000 Main Street Chadron, NE 69337 (719) 588-4492 [email protected]
Cross Country Camp June 28-30, 2015 Chadron, NE
Please submit registration form by JUNE 7, 2015
Your camp fee will include lodging in the residence halls, all meals, classes, activities (State Park trip), and a t-shirt. Please make check payable to Chadron State College Cross Country Camp.
Mileage/Wk Coach $100
Gender
Other Times Camper $150
17 time All-American 9 time national champion Professional runner for Boulder Running Company
Please circle one of the options below:
Alicia Nelson
Cassie Mitchell is a volunteer coach for Chadron State’s distance team. Cassie graduated from Orange Coast Community College in 2009 with an Associate’s in Kinesiology before graduating from Adams State College in 2011 with a Bachelor’s in HPPE. She earned 10 All-American honors during her time at Adams State, including a national title in the 3000 SC.
Best 2-Mile Time
15 time All-American 6 time national champion Professional runner for Adidas (5 yrs.) 2013 US National 12k Road Race Champion
Phone
The camp director is Brian Medigovich, the Head Men’s and Women’s Cross Country Coach. In just his second year of coaching at Chadron State, the men’s and women’s teams moved up 7 positions at the regional meet. Brian graduated from Adams State College in 2010 with a Bachelor’s in HPPE, earning 13 All-American honors, including a national title in the 5000M, as well as qualifying for 4 US national events.
Email City Age
Arrival Registration will be on Sunday June 28 from 2-4 PM. Departure Campers will be free to depart at 2 PM on Tuesday June 30. What to Bring Please bring a current physical form. A list of items needed for camp participation will be sent via email to each registered camper/school. Guest Speakers
Name Address Zip School Name Best Mile Time
Camp Staff
Camp Registration
Important Information
Aaron Braun
State T-shirt Size
Just 9 miles south of Chadron in the heart of the Nebraska National Forest lies Chadron State Park. The Pine Ridge provides a gorgeous backdrop for all 972 acres at nearly 5,000 feet.
2015 CSC Cross Country Camp Authorization and Release Form Note: In order for your child to participate in the 2015 Chadron State Cross Country Camp on June 28-30, this form must be completed, signed, and returned to the College prior to the first day of camp.
Child’s Printed Name
Child’s Date of Birth
Authorization
Key Offerings An educational experience regarding the sport of cross country with high level training, guest speakers, and the Chadron State coaching staff.
I authorize and give my consent for any licensed medical provider or athletic trainer to provide medical treatment, emergency services, or assistance to my child related to his/her participation in the 2015 Chadron State Cross Country Camp. I agree to assume all costs related to such treatment, services, or assistance.
As we begin to build our tradition here at Chadron State College, let us help you start or continue yours.
Insurance Company
Contact Us/Mail Form to:
Policy Number
Release I give permission for my child (identified above) to participate in the 2015 Chadron State Cross Country Camp. I assume all risks of accident or injury that may result from his/her participation in this activity. I release the Nebraska State Colleges, the Board of Trustees of the Nebraska State College, Chadron State College, and all officers, employees, agents, volunteers, and participants from liability including, but not limited to, legal claims and suits for any injury, damage or loss (personal or property) resulting from his/her participation in this activity.
Parent/Guardian Printed Name
Parent/Guardian Signature
Date
Chadron State College Cross Country Attn. to: Brian Medigovich 1000 Main Street Chadron, NE 69337 (719) 588-4492 [email protected]
Cross Country Camp June 28-30, 2015 Chadron, NE
Please submit registration form by JUNE 7, 2015
Your camp fee will include lodging in the residence halls, all meals, classes, activities (State Park trip), and a t-shirt. Please make check payable to Chadron State College Cross Country Camp.
Mileage/Wk Coach $100
Gender
Other Times Camper $150
17 time All-American 9 time national champion Professional runner for Boulder Running Company
Please circle one of the options below:
Alicia Nelson
Cassie Mitchell is a volunteer coach for Chadron State’s distance team. Cassie graduated from Orange Coast Community College in 2009 with an Associate’s in Kinesiology before graduating from Adams State College in 2011 with a Bachelor’s in HPPE. She earned 10 All-American honors during her time at Adams State, including a national title in the 3000 SC.
Best 2-Mile Time
15 time All-American 6 time national champion Professional runner for Adidas (5 yrs.) 2013 US National 12k Road Race Champion
Phone
The camp director is Brian Medigovich, the Head Men’s and Women’s Cross Country Coach. In just his second year of coaching at Chadron State, the men’s and women’s teams moved up 7 positions at the regional meet. Brian graduated from Adams State College in 2010 with a Bachelor’s in HPPE, earning 13 All-American honors, including a national title in the 5000M, as well as qualifying for 4 US national events.
Email City Age
Arrival Registration will be on Sunday June 28 from 2-4 PM. Departure Campers will be free to depart at 2 PM on Tuesday June 30. What to Bring Please bring a current physical form. A list of items needed for camp participation will be sent via email to each registered camper/school. Guest Speakers
Name Address Zip School Name Best Mile Time
Camp Staff
Camp Registration
Important Information
Aaron Braun
State T-shirt Size
Just 9 miles south of Chadron in the heart of the Nebraska National Forest lies Chadron State Park. The Pine Ridge provides a gorgeous backdrop for all 972 acres at nearly 5,000 feet.
