Register with Us

Please print this form, complete and mail to us with your payment

 

Vaulter's Name ___________________________________ T-Shirt Size XL L M S

Date of Birth _____________________________________

USATF Number ____________________

Best Phone Number _______________________________

Street Address ___________________________________

City, State, Zip ___________________________________

E-Mail Address ___________________________________

Height _______ Weight _______

Father's Name ___________________________________ PR _______

Father's Home Phone _____________________________

Father's Office Phone _____________________________

Father's Cell Phone _____________________________

Father's e-mail _____________________________

Mother's Name __________________________________

Mother's Home Phone (if different) __________________

Mother's Office Phone ____________________________

Mother's Cell Phone ____________________________

Mother's e-mail ____________________________

 

EMERGENCY CONTACT

NAME _________________________

PHONE _________________________

Make Check payable to Skyjumpers-Connecticut

Paid by check number _______________ ($20)

Mail To: Skyjumpers-Connecticut, 3 Lathrop Lane, Norwich, CT 06360

Russ's Cell Phone: 860-857-8503

Russ's e-mail: ancientlex@hotmail,com

 

Waiver of Liability, Medical Consent

In consideration of my son's/daughter's or ward's participation with Skyjumpers-Connecticut ("Skyjumpers"), I hereby for myself, my heirs, executors, and administrators, waive and release any and all rights or claims for damages I may have against Skyjumpers, its representatives, successors, employees, volunteers, coaches, staff, sponsors, directors, and assigns for any and all injuries suffered by my son/daughter or ward as a result of his/her participation in or travel to and from any practice, "open pit" session, meet, or other function of Skyjumpers. I, the undersigned, understand that there is an element of risk involved with my son/daughter or ward participating in pole vault activities, and that both minor and severe injuries may occur. On behalf of my son/daughter or ward, I accept the risks of such injuries, and voluntarily grant my permission for my son/daughter or ward to participate in all of the activities of Skyjumpers.

I also grant Skyjumpers, its employees, staff, volunteers, coaches, and other persons authorized and/ or designated by Skyjumpers to administer first aid as they deem reasonable and appropriate under the circumstances, while my son/daughter or ward is participating in the activities of Skyjumpers, including, but not limited to practices, "open pit" sessions, meets, and travel to and from the same. Such first aid shall include, but not be limited to, applying antiseptics and bandages, and in the event of my absence, seeking any other emergency medical treatment from heath care professionals that Skyjumpers, its employees, staff, coaches, volunteers, and other persons designated and/or authorized by Skyjumpers may deem reasonable and appropriate while my son/daughter or ward is participating in the activities of Skyjumpers, including, but not limited to practices, "open pit" sessions, meets, and travel to and from the same. In the event of an emergency in my absence, if any health care professional is consulted, I understand that I will be contacted as soon as possible, and that I will be financially responsible for any medical treatment administered by said healthcare professional.

Parent/Guardian Signature _____________________________________________

Date ___________________________