STEVE HAMANN WATER POLO CLINIC
FOR
GOALKEEPERS AND COACHES
PO Box 642
Cobb, CA 95426-0642
(707) 355-2155
This is a two day clinic
May 28th and 29th, 2011
Saturday, May 28
From 9 am -12 noon and 1 pm - 4 pm
AND
Sunday, May 29
From 9 am -12 noon and 1 pm - 4 pm
@
Solano Community College
4000 Suisun Valley Road
Fairfield, CA 94534-3197
The cost for this clinic is $200 per goalkeeper and $70 per coach.
Please send check/money order made out to Steve Hamann and mail to: PO Box 642, Cobb, CA 95426-0642.
Meals and lodging, if needed, are to be found separately.
I will be wearing a shirt and hat, on both days, to protect myself from the sun. I recommend you do the same.
Please prepare yourself for 6 hours in the water (6 hours of sun) on both days.
Name _______________________________________
(Please print)
Address __________________________
__________________________
____________________________
email address __________________________
Phone ____________________________
School ___________________________
WAIVER AND MEDICAL RELEASE FORM
I hereby authorize Steve Hamann and the staff of the “Steve Hamann Water Polo Clinic for Goalkeepers and Coaches” to act for me according to their best judgment in any emergency requiring medical attention for
____________________________________. And I hereby waive and release Solano Community College, the athletic department, clinic director, and clinic staff members from any and all liability for any injuries or illnesses incurred while at the clinic. I understand that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether or not my medical insurance would cover such costs. I further understand that I am required to maintain and carry accident insurance coverage for the person listed on this application and verify that the coverage information is accurate and true. I have no knowledge of any physical or mental impairment that would affect the above named applicant's participation in the goalkeeper clinic.
Applicant Name ___________________________________ Applicant signature ___________________________
(please print)
Parent/Guardian signature_____________________________
Parent/Guardian Work Phone# ______________________ Parent/Guardian Home Phone___________________
Medical Insurance Name __________________________ Medical Insurance Policy # ____________________
If parent/guardian cannot be contacted:
Name of Friend/Relative __________________________ Phone # of Friend/Relative _____________________
CAMPER INFORMATION
Allergies_______________________________ Is camper presently on medication? Y or N
Medical concerns to be aware of: ____________ If so, what?______________________________
_______________________________________
Upon payment, a letter of confirmation will be sent to you. The check/money order will not be cashed until week of May 17, 2010.
Thank you for your interest in my goalkeeper clinic.
Steve