It is very important to have this signed and filled out before you jump along with your USATF MEMBERSHIP. No waiver OR membership.....no practice! Its for the safety of the athletes.
Apex Pole Vault Club Registration Form/WaiverFull Name:___________________Male/Female:Email Address:________________Home Address:_________________________________City,State,Zip:________________________________________________
Parents’ Names:______________________________________________
_____________________________________________________________
Home Phone:(_____)________-__________
Vaulter’s Cell Phone:(_____)______-________
Emergency contact person__________________________________
CONTACT PHONE NUMBER:_________________________________
EXTRA NUMBER(S):________________________________________
Age:______DOB:___________
High School Graduation Year:___________________________________
School Name:_________________________________________________
School Coach:_________________________________________________
What is your PR(highest vault):___'_____"
Informed consent and Release
I hereby grant permission for myself / child to attend Apex Pole Vault Club. I verify that I / my child has had a physical exam in the past year and is capable to participate in the activities related to pole vaulting. I agree to indemnify, hold harmless, and defend all coaches and staff of Apex Pole Vault Club, USA Track and Field, their agents, employees and sponsors from any and all liability for injury to myself and/or my child. I understand that track and field, and in particular pole vaulting and many of its related activities are potentially dangerous and could pose risk of injury. Should medical attention be necessary, I hereby authorize any physician or trainer selected by the club personnel to conduct medical or surgical procedures. In addition, I hereby grant permission for Apex Pole Vault Club to use any photographs or videotape of club related activities for the purpose of advertising or educational materials development. I HAVE READ AND UNDERSTOOD, AND AGREE WITH THE INFORMED CONSENT AND RELEASE OUTLINED AS IT RELATES TO MYSELF/SON/DAUGHTER.
Participant Signature:___________________________________________________
Parent Guardian Signature:_______________________________________________
Register with the USATF:
We’re club # 0505 Apex Pole Vault Club
Las Vegas, Nevada
*Send Registration, USATF membership(receipt or copy of card) and payment to:
Anthony Waddle
4645 N. Cimarron RD
Las Vegas, Nevada 89129
