STEVE HAMANN WATER POLO CLINIC
FOR
GOALKEEPERS AND COACHES
PO Box 642
Cobb, CA 95426
(707) 355-2155
This is a two day clinic
his is a two day clinic
Saturday, July 9th
AND
Sunday, July 10th
2011
@
Bear River High School
11130 Magnolia Road
Grass Valley, California 95949
Saturday from 9 am - 12 noon and 1 pm - 4 pm
Sunday from 9 am - 12 noon and 1 pm - 4 pm
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.
We will be in the water and SUN for 6 hours each day.
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 _______________________________________ email address __________________________
(Please print)
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 Bear ?River Unified School District, 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 deposited until the week of July 4, 2011.
Thank you for your interest in my goalkeeper clinic.
Steve