2008 Clearwater River Cross Country Running Camp
July 14 – 18
REGISTRATION FORM
The Clearwater River Cross Country Running Camp is open to beginning and experienced runners entering grades 8-12. SPACE IS LIMITED TO THE FIRST 50 REGISTRANTS, SO REGISTER EARLY!
- The cost of the camp is $240 per camper if registered by June 1, or $210 per camper if 5 or more registrations are submitted together.
- After June 1 the costs are $275 individually or $245 with 5 or more registration submitted together.
- A full refund, minus a $50 processing fee if registration is cancelled in writing by May 1, 50% will be refunded if cancelled by June 1. No refunds will be given for cancellations after June 1. Registration is non-transferable.
Check in is July 14 from 1:00-3:00 pm with orientation at 3:30pm. Camp officially ends July 18 at 3:00pm.
Send registration form with your check payable to:
LCSC Cross Country
Attn: Mike Collins, Head Coach
Lewis-Clark State College
500 8th AVE
Lewiston, ID 83501
NAME: ____________________________________ AGE: ______ GENDER: Male or Female
ADDRESS: _____________________________ CITY: __________________ STATE: _____ ZIP: _______
HOME PHONE: ( ) _____ - ________ CELL PHONE: ( ) _____ - ________
EMAIL: ____________________________ EMERGENCY PHONE: ( ) _____ - ________
PARENT/GUARDIAN: _____________________________________ PHONE: ( ) _____ - ________
EMAIL: _______________________________ Current Coach’s Name: ___________________________
SCHOOL: ________________________ Grade (Sept 2008): _________ Date of Birth: _____/_____/_____
Personal Bests (if known): 800m_______ 1500/1600m_______ 3000/3200m_______ 3mi/5000m_______
Approximately how many miles per week will you have averaged in the 3 weeks before camp: ________
T-Shirt Size (Circle One): Small Medium Large X-Large
List any Food, Beverage or medicinal products your child may not have or is allergic to:
CONSENT AND RELEASE AGREEMENT
I am aware that participation in Clearwater Cross Country Running Camp may include activities that are risky and dangerous. Both participant and their parent (s) / guardians (“I”) acknowledge and accept the risks and give permission for participation in the Program. I acknowledge that participation has activities that bear risk and danger and from which bodily injury up to and including mortal injury, may occur: academic learning opportunities while on campus or off; field trips; activities supplemental to the Program, such as walking or hiking to and from sites of interest; use or operation, by myself or others, of equipment; physical and sports activities, including, but not limited to, swimming, boating, and other water sport activities; being outside or in the presence of inclement weather conditions including, but not limited to, lightning, wind, and rock fall; contact with plants, animals or other environmental hazards; transit to or from the camp locations and activity locations including but not limited to travel by bus, van or private auto; use of roads, trails, waterways, terrain, and other routes or water flows in the condition in which they are found; staying overnight on or off campus; rendering of first-aid, emergency treatment or other services; consumption of food or drink; or other unknown and unanticipated activities and risks.
In consideration of Lewis-Clark State College, I and my dependent hereby voluntarily assume all risks associated with participation. To the extent permitted by law, I agree to indemnity, defend, save, hold harmless, discharge and release the State of Idaho, Lewis-Clark State College, their agents and employees from any and all liability, claims, causes of action or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the Clearwater River Cross Country Running Camp.
It is my express intent that this Acknowledgement of Risk and Waiver of Liability shall serve as a release, discharge and assumption of risk for my heirs, estate, executor, administrator, assignees and all members of my family. I am aware that if I provide a vehicle not owned and operated by the college for transportation to, at, or from the Activity site, or if I am a passenger in such a vehicle, the College is not responsible for any damage caused by or arising from my use of such transportation. Furthermore, I acknowledge that I am solely responsible for any action that I take that is outside the scope of the scheduled Activity activities, regardless if occurring before, during or after the period of the Activity.
I hereby certify that, with or without accommodation, I and/or my dependant is in good health and I know of no medical reason why he/she is not able to participate in this program. I hereby consent to first aid, emergency medical care and if necessary, admission to an accredited hospital when necessary for executing such care, for treatment for injuries that he/she may sustain while participating in any Program associated with the Clearwater River Cross Country Running Camp.
I understand that smoking, use of illegal drugs and/or alcohol is not permitted. I also understand that the director reserves the right to send home, at parent/guardian’s expense, any individual or group who violates camp rules or other policies or in any way is not willing to further the interest of the camp community. Campers sent home on such terms will not receive a refund. I agree that any damage to school or camp property will be at the camper’s expense. Finally, I understand that violation of camp rules will jeopardize future attendance for any individual or school.
I understand that any insurance provided through this program provides only limited protection for injuries which occur while participation and that I am responsible for all medical expenses not covered by program insurance. Program insurance is provided by an American Income Life camp accident policy.
I have read the entire Consent and Release Agreement and accept the conditions state herein as a requirement for my child’s participation in this camp.
Signature of Camper: _______________________________ Date: ___________
Signature of Parent: ________________________________ Date: __________
Upon receipt we will mail or email you confirmation. Required forms and all other pertinent camp information may be downloaded from the camp website. Required forms MUST BE COMPLETED and submitted at check in for participation in the camp.
A photocopy of the student’s health insurance card must be provided with this application.