Temple University Softball Clinic
M E D I C A L
W A I V E R
Temple University
I hereby authorize the staff of the Temple University, trustee, agents, employ-
Softball Clinic
ees, etc, softball clinic/camp to act for me in accordance with their best judgment in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for any injuries or illnesses incurred while at clinic/camp. I have no knowledge of any physical impairment that would be affected by the above named campers participation in the camp program, as outlined in this brochure. ______________________________________ Parent or Guardian Signature ______________________________________ Name of Health Insurance Provider ______________________________________ Agreement #
Group
Please note any medical conditions that we should be aware of: ______________________________________
PL EA SE
N OT E :
CL I NI CS, PRO VI DE ACCID E NT CAM PE RS O N
T HE IR
M EDI CA L
WE
F OR DO
A L L
N OT
HE A LT H
&
I N SUR AN CE. M U ST
R E LY
G U ARDIA N ’S S ER VIC ES.
I NS URA NC E I NF OR M AT I O N I NC LU DED
M US T O N
APP L ICA T IO N . SP ORT S
BY
M E MBER S. U NIV ER SI TY AL L
TH E M I N OR
I N JU RIE S
TREA TE D
AR E
STA F F
T E MP LE WA IVE S
R ES P ON S IB I LI T IE S
F OR
T REA T M EN T
O F
CAM P- R E LAT ED I NJ UR I ES.
February 3, 2013 Sunday 9:00am – 1:00pm Open to any and all ages!
$100.00 per person McGonigle Hall
Temple University Staff: Joe DiPietro – Head Coach Chrissy Focht – Assistant Coach
______________________________________ ______________________________________
BE
For Clinic Dir ec ti on s a nd r eg istr a ti on for m … S ee www.OwlS p or t s .c om
Giannina Cipolloni – Assistant Coach
Temple University Softball Attn: Softball Office 1800 No Broad Street
ALL SKILLS CLINIC
_________________________________________
Includes:
_________________________________________
Room 106 TU Zip 048-05
Pitching
Philadelphia, Pa 19122
Catching
215-204-8742 [email protected] www.OwlSports.com MAKE CHECKS PAYABLE TO :
Temple University Softball
Registration Form;
Name
Age
Address _________________________________________
City/ State/ Zip Code _________________________________________
Infield Outfield Hitting
Email _________________________________________
Positions
*Open to any and all ages!
Waiver must be submitted with Registration!!
W A I V E R
Temple University
I hereby authorize the staff of the Temple University, trustee, agents, employ-
Softball Clinic
ees, etc, softball clinic/camp to act for me in accordance with their best judgment in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for any injuries or illnesses incurred while at clinic/camp. I have no knowledge of any physical impairment that would be affected by the above named campers participation in the camp program, as outlined in this brochure. ______________________________________ Parent or Guardian Signature ______________________________________ Name of Health Insurance Provider ______________________________________ Agreement #
Group
Please note any medical conditions that we should be aware of: ______________________________________
PL EA SE
N OT E :
CL I NI CS, PRO VI DE ACCID E NT CAM PE RS O N
T HE IR
M EDI CA L
WE
F OR DO
A L L
N OT
HE A LT H
&
I N SUR AN CE. M U ST
R E LY
G U ARDIA N ’S S ER VIC ES.
I NS URA NC E I NF OR M AT I O N I NC LU DED
M US T O N
APP L ICA T IO N . SP ORT S
BY
M E MBER S. U NIV ER SI TY AL L
TH E M I N OR
I N JU RIE S
TREA TE D
AR E
STA F F
T E MP LE WA IVE S
R ES P ON S IB I LI T IE S
F OR
T REA T M EN T
O F
CAM P- R E LAT ED I NJ UR I ES.
February 3, 2013 Sunday 9:00am – 1:00pm Open to any and all ages!
$100.00 per person McGonigle Hall
Temple University Staff: Joe DiPietro – Head Coach Chrissy Focht – Assistant Coach
______________________________________ ______________________________________
BE
For Clinic Dir ec ti on s a nd r eg istr a ti on for m … S ee www.OwlS p or t s .c om
Giannina Cipolloni – Assistant Coach
Temple University Softball Attn: Softball Office 1800 No Broad Street
ALL SKILLS CLINIC
_________________________________________
Includes:
_________________________________________
Room 106 TU Zip 048-05
Pitching
Philadelphia, Pa 19122
Catching
215-204-8742 [email protected] www.OwlSports.com MAKE CHECKS PAYABLE TO :
Temple University Softball
Registration Form;
Name
Age
Address _________________________________________
City/ State/ Zip Code _________________________________________
Infield Outfield Hitting
Email _________________________________________
Positions
*Open to any and all ages!
Waiver must be submitted with Registration!!
