MEN'S RUGBY ELITE PROSPECT CAMP
2017
CENTRAL WASHINGTON UNIVERSITY
MEN’S RUGBY ELITE PROSPECT CAMP JULY 22, 2017 8 a.m. - 4 p.m.
CONTACT Todd Thornley PHONE: 509-963-2312 E-MAIL: [email protected]
Central Washington University Men’s Rugby welcomes high school students ages 14-18 and community college students to the 2017 Men’s Rugby Elite Prospect Camp. This camp is committed to providing skill instruction and player development in all basic aspects of rugby, suitable for both new and experienced players. Led by CWU coaches and players, as well as Atavus coaches, some of the top names in rugby will be providing fun, team focused activities designed to showcase your talents.
WHAT TO BRING
REGISTRATION DUE JULY 8, 2017 Cost: $125 Location: Wildcat Rugby Pitch Check in: 8 a.m. Camp: 9 a.m. - 4 p.m. Lunch: 12 p.m. - 1 p.m. Camp Concludes: 4 p.m. Limit: 60 Players
Rugby Cleats, Running Shoes, Athletic T-Shirt, Rugby Shorts, Protective/ Supportive Gear, lunch, snacks and a Water Bottle. Please leave all valuables at home. CWU is not responsible for damage or loss of personal property. If you are traveling from out of state and are arriving early, we highly encourage you to contact Campus Tours (509-963-1262) and set up a tour on Friday. CAMP T-SHIRT WILL BE INCLUDED • PROVIDE YOUR OWN LUNCH The camp is hosted at the Wildcat Rugby Pitch, located on the CWU Campus (400 East University Way, Ellensburg, WA 98926).
SCHEDULE: CHECK IN: 8 a.m. - 8:30 a.m. MORNING: 9 a.m. - Noon Session 1 LUNCH: Noon - 1 p.m. Lunch is NOT provided. Please pack your own lunch AFTERNOON: 1 p.m. - 4 p.m. Session 2 FORMS ARE AVAILABLE ONLINE. Please remember the camp will fill up fast and it is first-come, first-served. Payments and registration are due NO LATER than July 8, 2017. No refunds will be issued, unless the minimum number of campers is not reached. However, if an unforeseen event occurs, we will allow you to put payment toward a future camp. Forms must be mailed in, online registration is NOT available.
WILDCATSPORTS.COM CWU is an AA/EEO/Title IX/Veteran/Disability employer. For accommodation: [email protected].
CENTRAL WASHINGTON UNIVERSITY
WILDCAT RUGBY REGISTRATION//////////////////// FORM ///// REGISTER BY: July 8, 2017
DATES: Saturday, July 22, 2017 CAMP: 8:00 a.m. - 4:00 p.m. LUNCH: 12:00 - 1:00 p.m. (Lunch will NOT be provided) AGES: High School Students aged 14-18 LOCATION: Wildcat Rugby Pitch STAFF: CWU Rugby Staff, Atavus Coaches, and CWU Players COST: $125 NAME GRAD YEAR E-MAIL MOBILE PHONE ADDRESS CITY STATE ZIP CODE HIGH SCHOOL GPA HIGH SCHOOL TEAM NAME HEIGHT PRIMARY POSITION
WEIGHT
SECONDARY POSITION
OTHER TEAMS (ALL-STARS, SUMMER 7s, ETC.)
T-SHIRT SIZE:
S
M
L
XL
XXL
(Please read before sending information to CWU Men’s Rugby)
MAILING ADDRESS CWU Men’s Rugby ATTN: Todd Thornley 400 E. University Way Ellensburg, WA 98926-7570
PLEASE MAIL IN THE FOLLOWING: 1. Registration Form 2. Proof of Physical documentation within the last two years 3. Hold Harmless Form (next page) 4. Liability Waiver (Following page) 5. Check made out to CWU Rugby (Write camper’s name in memo)
WILDCATSPORTS.COM CWU is an AA/EEO/Title IX/Veterans/Disability employer. For accommodation: [email protected].
CENTRAL WASHINGTON UNIVERSITY
WILDCAT RUGBY LIABILITY WAIVER //////////////////// ///// ACKNOWLEDGEMENT OF RISK AND CONSENT FOR TREATMENT OF MINOR PARTICIPANTS (TO BE COMPLETED BY PARENTS)
Players attending the Central Washington University Men’s Rugby Elite Prospect Camp offered by the CWU Men’s Rugby program will participate in physical activity and sport activities. Some of the activities planned may involve inherent risk. I/We, the undersigned, fully understand there is inherent risk associated with my/our minor child’s participation in the winter camp described above and I/we voluntarily assume full responsibility for any consequences which may result during my/our minor child’s participation. I/We hereby agree to release, both in their individual and official capacities, the state of Washington, Central Washington University, its board of trustees, officers, agents, employees, students and volunteers from any and all claims and losses resulting from damages or injuries which my/our minor child may cause or sustain. I/We verify that my/our child’s participation in this activity as well as travel to and from the activity. Furthermore, I/we verify that my/our minor child is capable, with or without reasonable accommodation, to participate in the Men’s Rugby Elite Prospect Camp presented by CWU Men’s Rugby. Should my minor require emergency medical treatment as a result of an accident or illness arising during the CWU Men’s Rugby Elite Prospect Camp I consent to such treatment. I agree to be financially responsible for any medical bills as a result of emergency medical treatment.
Name of Athlete Birth Date
/
/
Name of Parent/Guardian (Please Print) IN CASE OF EMERGENCY, PLEASE CONTACT ME AT: Daytime phone (
)
Mobile phone (
)
Name Signature Date
WILDCATSPORTS.COM CWU is an AA/EEO/Title IX/Veterans/Disability employer. For accommodation: [email protected].
CWU CAMPER HEALTH/EMERGENCY INFORMATION AND HOLD-HARMLESS FORM FOR CWU SPORTS CAMPS WILDCAT RUGBY CAMPS Men’s Rugby Elite Prospect Camp
JULY 22, 2017
THIS FORM AND A VALID PHYSICAL FITNESS STATEMENT MUST BE PROPERLY SIGNED and RETURNED BY REGISTRATION DEADLINE. Campers will not be allowed to participate without properly completed and signed forms.
Participant’s Name_________________________________________________________ (Please print) Address_ _________________________________________________________________ City ____________________________________ State _______ Zip _ _______________ Birth Date ______________________ Phone (________) _ ________________________ (Month/Day/Year) (Area Code) Sports Camp Attending _ ___________________________________________________ Camp Dates ______________________________________________________________
IN CASE OF EMERGENCY, NOTIFY: Name____________________________________________________________________ (Please print) Relationship ______________________________________________________________ Address_ _________________________________________________________________ City ____________________________________ State _______ Zip _ _______________ Phone: Work (_______) __________________ Home (_______) _____________________ (Area Code) (Area Code) Family Physician _________________________ Phone (_______) ___________________ (Area Code)
DOES YOUR CHILD HAVE:
Medical Insurance _________________________________________________________
Allergies n Yes n No If yes, list. _ ___________________________________________
Name of Insured __________________________________________________________
_________________________________________________________________________
Policy/Group # _ __________________________________________________________
Chronic Illness, such as heart condition, asthma, epilepsy, diabetes, etc.
I, the undersigned, individually and as a parent/guardian of _____________________________________________________________ (participant), a minor, ask that he/she be admitted to participate in the sports camp sponsored by Central Washington University (CWU). I am fully aware of the safety risks of participating in this activity.
n Yes n No If yes, list._____________________________________________________ _________________________________________________________________________ Has your child had any injuries and/or operations during the past year? n Yes n No If yes, list type and dates._ ______________________________________ _________________________________________________________________________ Has your child’s physical activity been restricted during the past year? n Yes n No If yes, list reasons and duration.__________________________________ _________________________________________________________________________ Is your child taking any medications? n Yes n No If yes, why?___________________ _________________________________________________________________________ Name of medication(s) and Dosage(s). ________________________________________ _________________________________________________________________________ Has your child ever taken any sulfa drugs? n Yes n No Has your child had adverse reactions to any drugs? n Yes n No If yes, list drug(s) and reaction(s): ____________________________________________ _________________________________________________________________________ Date of last tetanus immunization:___________________________________________
I acknowledge and accept the risks and I understand that CWU cannot guarantee my child’s safety. I state to you that I am not aware of any physical condition that would limit my child’s participation in this activity. I understand that it is my responsibility to let you know if my child has any condition that would limit his/her ability to safely participate in this activity. In exchange for my child being allowed to participate in this activity, and to the fullest extent permitted by law, I hereby waive and release—and further agree to indemnify, defend, and hold harmless CWU and its trustees, officers, agents, employees, and volunteers from and against—any and all liabilities, claims, costs, expenses, injuries, and or/losses that I or my minor child may sustain as a result of my child’s attendance at the sports camp, or in the course of competition and/or activities held in connection with the sports camp. I hereby give consent for medical treatment and agree to assume all responsibility for payment of medical bills and expenses. Furthermore, I will be responsible for filing all claims with all insurance companies. You have my permission to release a copy of this form and the personal insurance information below to any medical provider treating my child. I agree to pay for lost keys and damages caused by my child while at camp. I also give permission for my child’s photograph to appear in promotional material regarding future camps. Signature of Parent/Guardian____________________________________ Date (Please print name and relationship to participant)
Coaches: Please make copies for each participant.
CENTRAL WASHINGTON UNIVERSITY
ACKNOWLEDGMENT OF RISKS AND RELEASE OF CLAIMS ACKNOWLEDGMENT OF RISKS. I understand that my participation in the CWU sports camp program involves potential risks to my health or safety. Such risks may include falls, collisions with other participants, heat exhaustion, rhabdomyolysis, paralyzation, broken bones, torn ligaments, sprains, concussions, heart failure, permanent injury and such other injuries or illnesses as can occur in the course of vigorous physical activity. I understand that my participation in the program is voluntary. I acknowledge and voluntarily assume the risks of my participation, whether such risks result from my own negligence, the negligent acts or omissions of others, faulty equipment, or otherwise. I further understand that I am solely responsible for determining whether I am physically capable of participating in the program and whether I have any medical or health condition that would prevent me from participating safely. I hereby authorize CWU staff to seek emergency medical services for me should I become injured or ill with the understanding that I will be solely responsible for any and all resulting medical expenses. WAIVER AND RELEASE OF CLAIMS. As a condition of my being permitted to participate in the CWU sports camp program, I hereby waive and release any claims that I or my estate may have against CWU or its staff or volunteers based on any injuries, illnesses, or property damage that I may sustain as a result of my participation in the program. If the participant is under the age of 18, the signature of a parent or guardian is required. If I am signing as a parent or guardian of a minor child, I hereby acknowledge and accept the above risks of my child’s participation in the program, and I waive and release any claims that I or we may have against CWU as stated in the above Waiver and Release of Claims.
Participants Name: Phone Number:
(Please Print)
Address: Emergency Contact: Phone Number: Participant’s Signature:
(Parent or guardian if under the age of 18)
Date:
CENTRAL WASHINGTON UNIVERSITY
MEN’S RUGBY ELITE PROSPECT CAMP JULY 22, 2017 8 a.m. - 4 p.m.
CONTACT Todd Thornley PHONE: 509-963-2312 E-MAIL: [email protected]
Central Washington University Men’s Rugby welcomes high school students ages 14-18 and community college students to the 2017 Men’s Rugby Elite Prospect Camp. This camp is committed to providing skill instruction and player development in all basic aspects of rugby, suitable for both new and experienced players. Led by CWU coaches and players, as well as Atavus coaches, some of the top names in rugby will be providing fun, team focused activities designed to showcase your talents.
WHAT TO BRING
REGISTRATION DUE JULY 8, 2017 Cost: $125 Location: Wildcat Rugby Pitch Check in: 8 a.m. Camp: 9 a.m. - 4 p.m. Lunch: 12 p.m. - 1 p.m. Camp Concludes: 4 p.m. Limit: 60 Players
Rugby Cleats, Running Shoes, Athletic T-Shirt, Rugby Shorts, Protective/ Supportive Gear, lunch, snacks and a Water Bottle. Please leave all valuables at home. CWU is not responsible for damage or loss of personal property. If you are traveling from out of state and are arriving early, we highly encourage you to contact Campus Tours (509-963-1262) and set up a tour on Friday. CAMP T-SHIRT WILL BE INCLUDED • PROVIDE YOUR OWN LUNCH The camp is hosted at the Wildcat Rugby Pitch, located on the CWU Campus (400 East University Way, Ellensburg, WA 98926).
SCHEDULE: CHECK IN: 8 a.m. - 8:30 a.m. MORNING: 9 a.m. - Noon Session 1 LUNCH: Noon - 1 p.m. Lunch is NOT provided. Please pack your own lunch AFTERNOON: 1 p.m. - 4 p.m. Session 2 FORMS ARE AVAILABLE ONLINE. Please remember the camp will fill up fast and it is first-come, first-served. Payments and registration are due NO LATER than July 8, 2017. No refunds will be issued, unless the minimum number of campers is not reached. However, if an unforeseen event occurs, we will allow you to put payment toward a future camp. Forms must be mailed in, online registration is NOT available.
WILDCATSPORTS.COM CWU is an AA/EEO/Title IX/Veteran/Disability employer. For accommodation: [email protected].
CENTRAL WASHINGTON UNIVERSITY
WILDCAT RUGBY REGISTRATION//////////////////// FORM ///// REGISTER BY: July 8, 2017
DATES: Saturday, July 22, 2017 CAMP: 8:00 a.m. - 4:00 p.m. LUNCH: 12:00 - 1:00 p.m. (Lunch will NOT be provided) AGES: High School Students aged 14-18 LOCATION: Wildcat Rugby Pitch STAFF: CWU Rugby Staff, Atavus Coaches, and CWU Players COST: $125 NAME GRAD YEAR E-MAIL MOBILE PHONE ADDRESS CITY STATE ZIP CODE HIGH SCHOOL GPA HIGH SCHOOL TEAM NAME HEIGHT PRIMARY POSITION
WEIGHT
SECONDARY POSITION
OTHER TEAMS (ALL-STARS, SUMMER 7s, ETC.)
T-SHIRT SIZE:
S
M
L
XL
XXL
(Please read before sending information to CWU Men’s Rugby)
MAILING ADDRESS CWU Men’s Rugby ATTN: Todd Thornley 400 E. University Way Ellensburg, WA 98926-7570
PLEASE MAIL IN THE FOLLOWING: 1. Registration Form 2. Proof of Physical documentation within the last two years 3. Hold Harmless Form (next page) 4. Liability Waiver (Following page) 5. Check made out to CWU Rugby (Write camper’s name in memo)
WILDCATSPORTS.COM CWU is an AA/EEO/Title IX/Veterans/Disability employer. For accommodation: [email protected].
CENTRAL WASHINGTON UNIVERSITY
WILDCAT RUGBY LIABILITY WAIVER //////////////////// ///// ACKNOWLEDGEMENT OF RISK AND CONSENT FOR TREATMENT OF MINOR PARTICIPANTS (TO BE COMPLETED BY PARENTS)
Players attending the Central Washington University Men’s Rugby Elite Prospect Camp offered by the CWU Men’s Rugby program will participate in physical activity and sport activities. Some of the activities planned may involve inherent risk. I/We, the undersigned, fully understand there is inherent risk associated with my/our minor child’s participation in the winter camp described above and I/we voluntarily assume full responsibility for any consequences which may result during my/our minor child’s participation. I/We hereby agree to release, both in their individual and official capacities, the state of Washington, Central Washington University, its board of trustees, officers, agents, employees, students and volunteers from any and all claims and losses resulting from damages or injuries which my/our minor child may cause or sustain. I/We verify that my/our child’s participation in this activity as well as travel to and from the activity. Furthermore, I/we verify that my/our minor child is capable, with or without reasonable accommodation, to participate in the Men’s Rugby Elite Prospect Camp presented by CWU Men’s Rugby. Should my minor require emergency medical treatment as a result of an accident or illness arising during the CWU Men’s Rugby Elite Prospect Camp I consent to such treatment. I agree to be financially responsible for any medical bills as a result of emergency medical treatment.
Name of Athlete Birth Date
/
/
Name of Parent/Guardian (Please Print) IN CASE OF EMERGENCY, PLEASE CONTACT ME AT: Daytime phone (
)
Mobile phone (
)
Name Signature Date
WILDCATSPORTS.COM CWU is an AA/EEO/Title IX/Veterans/Disability employer. For accommodation: [email protected].
CWU CAMPER HEALTH/EMERGENCY INFORMATION AND HOLD-HARMLESS FORM FOR CWU SPORTS CAMPS WILDCAT RUGBY CAMPS Men’s Rugby Elite Prospect Camp
JULY 22, 2017
THIS FORM AND A VALID PHYSICAL FITNESS STATEMENT MUST BE PROPERLY SIGNED and RETURNED BY REGISTRATION DEADLINE. Campers will not be allowed to participate without properly completed and signed forms.
Participant’s Name_________________________________________________________ (Please print) Address_ _________________________________________________________________ City ____________________________________ State _______ Zip _ _______________ Birth Date ______________________ Phone (________) _ ________________________ (Month/Day/Year) (Area Code) Sports Camp Attending _ ___________________________________________________ Camp Dates ______________________________________________________________
IN CASE OF EMERGENCY, NOTIFY: Name____________________________________________________________________ (Please print) Relationship ______________________________________________________________ Address_ _________________________________________________________________ City ____________________________________ State _______ Zip _ _______________ Phone: Work (_______) __________________ Home (_______) _____________________ (Area Code) (Area Code) Family Physician _________________________ Phone (_______) ___________________ (Area Code)
DOES YOUR CHILD HAVE:
Medical Insurance _________________________________________________________
Allergies n Yes n No If yes, list. _ ___________________________________________
Name of Insured __________________________________________________________
_________________________________________________________________________
Policy/Group # _ __________________________________________________________
Chronic Illness, such as heart condition, asthma, epilepsy, diabetes, etc.
I, the undersigned, individually and as a parent/guardian of _____________________________________________________________ (participant), a minor, ask that he/she be admitted to participate in the sports camp sponsored by Central Washington University (CWU). I am fully aware of the safety risks of participating in this activity.
n Yes n No If yes, list._____________________________________________________ _________________________________________________________________________ Has your child had any injuries and/or operations during the past year? n Yes n No If yes, list type and dates._ ______________________________________ _________________________________________________________________________ Has your child’s physical activity been restricted during the past year? n Yes n No If yes, list reasons and duration.__________________________________ _________________________________________________________________________ Is your child taking any medications? n Yes n No If yes, why?___________________ _________________________________________________________________________ Name of medication(s) and Dosage(s). ________________________________________ _________________________________________________________________________ Has your child ever taken any sulfa drugs? n Yes n No Has your child had adverse reactions to any drugs? n Yes n No If yes, list drug(s) and reaction(s): ____________________________________________ _________________________________________________________________________ Date of last tetanus immunization:___________________________________________
I acknowledge and accept the risks and I understand that CWU cannot guarantee my child’s safety. I state to you that I am not aware of any physical condition that would limit my child’s participation in this activity. I understand that it is my responsibility to let you know if my child has any condition that would limit his/her ability to safely participate in this activity. In exchange for my child being allowed to participate in this activity, and to the fullest extent permitted by law, I hereby waive and release—and further agree to indemnify, defend, and hold harmless CWU and its trustees, officers, agents, employees, and volunteers from and against—any and all liabilities, claims, costs, expenses, injuries, and or/losses that I or my minor child may sustain as a result of my child’s attendance at the sports camp, or in the course of competition and/or activities held in connection with the sports camp. I hereby give consent for medical treatment and agree to assume all responsibility for payment of medical bills and expenses. Furthermore, I will be responsible for filing all claims with all insurance companies. You have my permission to release a copy of this form and the personal insurance information below to any medical provider treating my child. I agree to pay for lost keys and damages caused by my child while at camp. I also give permission for my child’s photograph to appear in promotional material regarding future camps. Signature of Parent/Guardian____________________________________ Date (Please print name and relationship to participant)
Coaches: Please make copies for each participant.
CENTRAL WASHINGTON UNIVERSITY
ACKNOWLEDGMENT OF RISKS AND RELEASE OF CLAIMS ACKNOWLEDGMENT OF RISKS. I understand that my participation in the CWU sports camp program involves potential risks to my health or safety. Such risks may include falls, collisions with other participants, heat exhaustion, rhabdomyolysis, paralyzation, broken bones, torn ligaments, sprains, concussions, heart failure, permanent injury and such other injuries or illnesses as can occur in the course of vigorous physical activity. I understand that my participation in the program is voluntary. I acknowledge and voluntarily assume the risks of my participation, whether such risks result from my own negligence, the negligent acts or omissions of others, faulty equipment, or otherwise. I further understand that I am solely responsible for determining whether I am physically capable of participating in the program and whether I have any medical or health condition that would prevent me from participating safely. I hereby authorize CWU staff to seek emergency medical services for me should I become injured or ill with the understanding that I will be solely responsible for any and all resulting medical expenses. WAIVER AND RELEASE OF CLAIMS. As a condition of my being permitted to participate in the CWU sports camp program, I hereby waive and release any claims that I or my estate may have against CWU or its staff or volunteers based on any injuries, illnesses, or property damage that I may sustain as a result of my participation in the program. If the participant is under the age of 18, the signature of a parent or guardian is required. If I am signing as a parent or guardian of a minor child, I hereby acknowledge and accept the above risks of my child’s participation in the program, and I waive and release any claims that I or we may have against CWU as stated in the above Waiver and Release of Claims.
Participants Name: Phone Number:
(Please Print)
Address: Emergency Contact: Phone Number: Participant’s Signature:
(Parent or guardian if under the age of 18)
Date:
