WHEN: ___________________________
WHERE: George Mason University
TIME: 8:00am-11:00am
FEE: $150.00 per person
CONTACT: Dalton Ebanks GMU Mens Track, 4400 University Drive. 3A5, Fairfax, VA 22030
voice: 703-993-3285
fax: 703-993-3591
 

Application

Name: ________________________________________________________________

Address: ______________________________________________________________

Parents Name: __________________________________________________________

Home Phone: ___________________________________________________________

Emergency Phone: _______________________________________________________

Age at Camp: ___________________________________________________________

Name of School: ________________________________________________________

Name of Family Physician: ________________________________________________

Name of Medical Insurance Company: _______________________________________

Policy Number: _________________________________________________________

Make Checks Payable to: Patriot Track & Field Clinic

Medical Consent Form: I hereby state thtat my child is in good normal health and has my permission to participate in all camp actitivites. In addition, I authorize the Patriot Track and Field Clinic staff to act for me in securing medical treatment for my child in the event of injury or sickness.  A registration requires that a parent/guardian sign below to agree that in case of an accident involving their child while attending the Patriot Track and Field Clinic, they release the camp, ownership, counselors, directors, and George Mason University from any and all liability.

Signed (Parent/Guardian): _________________________________________________

Date: __________________________________________________________________

Instructor: Jim Keys. Coach Keys has been coaching the pole vault for over 15 years. He has worked with state champions, IC4A champions, and NCAA champions, as well as several olympians. Coach Keys was a pole vaulter/decathlete for GMU and was the training partner for Olympic Decathlete Rob Muzzio (5th, Decathlon, Barcelona, 1992).

Note: We are guests of GMU and will behave as such. It is both an honor and a privilege to be permitted to jump in their fine facility. We owe them a debt of gratitude for their generosity. Also, PV poles are specifically designed to your height, weight, speed, and ability, and therefore are more customized to your abilities than your underwear. As such, you must bring your own pole (and your own underwear too).