Saturday, November 8, 2014 Ages 13 ~ 18

Clinic Application
Type or print with ink only (form may be duplicated)
Please register me for the following clinic:
_____
IUP SWIM CAMP,
November 8, 2014
I am enclosing $65 in full payment (no cash)
Register and make payments at www.iup.edu/
camps
(MasterCard, AmeExpress, Discover, and Electronic Check)
Last Name
First Name
Advanced Performance Showcase
MI
Home Address (number, street and box no.)
State
Home Phone
Zip
Parent’s Business Phone
Email Address
Age
Date of Tetanus Immunization
T-shirt Size
Parent/Guardian Signature
Date
Or Email Form To: [email protected]
Questions On Payment(s) Contact: 724.357.2057
For Office Use only: Swimming
Check #
Amt. Rec. $
4012204234
IUP Athletics
Attn: Business Office
Room 107, MFH
Indiana PA 15705
Chris Villa
Memorial Field House, Room 101
660 South Eleventh St.
Indiana, PA 15705
In order for the camper to participate, please complete
the Medical Authorization Form and for war d it to:
IUP is a member of Pennsylvania’s State System of Higher Education.
City
Saturday, November 8, 2014
Ages 13 ~ 18
Register online @ www.iup.edu/camps
Chris Villa begins his 89h season at IUP for the 2014-15
year. Throughout his eight
years at IUP, the Crimson
Hawks have rewritten the
school record board, setting
73 new marks.
Clinic Dates:
AUTHORIZATION FOR MEDICAL CARE
______________________________________________
Saturday November 8, 2014
FULL NAME
Technique work for all four competitive strokes.
ADDRESS

Specialized workout based on base line test set.
PARENT / GUARDIAN NAME

Participants will experience the IUP campus and
also finishing 11th in the 100 butterfly and setting
school records in all three events.
Tips on stretching and core dryland exercises to
Athletes will get to swim with PSAC Record holders and NCAA All-Americans.

IUP swimming t-shirt
Pawel Glowiak earned All-America honors five
times, including three times in the 100 backstroke
and once each in the 200 backstroke and 100
butterfly. Glowiak was also a two-time recipient
of the PSAC Top 10 award which combines ath-
______________________________________________
HOME PHONE
EMERGENCY CONTACT PERSON
build swimming specific strength and endurance.

______________________________________________
EMERGENCY PHONE
______________________________________________
cafeteria.

BIRTHDAY
______________________________________________

In 2009-10, sophomore Jackie
Hynson became the first IUP woman to earn AllAmerica honors in four years, taking third place in
both the 200 butterfly and 200 backstroke while
SOCIAL SECURITY NUMBER
Clinic Highlights:
SEX
______________________________________________
EMERGENCY PHONE
HEALTH HISTORY
______________________________________________
OPERATIONS OR SERIOUS ILLNESS
______________________________________________
CHRONIC OR RECURRING ILLNESSES
______________________________________________
EMOTIONAL CONCERNS
______________________________________________
CURRENTLY UNDER MEDICAL CARE AND IF SO WHY
______________________________________________
CURRENTLY ON MEDICATION AND IF SO NAME OF MED, DOSAGE, AND AMOUNT
Tentative Clinic Schedule
______________________________________________
ALLERGIES LIST
CHECK ALL THAT APPLY AND LIST DATES
9:45 a.m.
Registration
10:00 a.m.
Campus Tour
letic and academic excellence.
11:30 a.m.
Lunch in cafeteria
The women's 800 freestyle relay team of Jen
12:30 p.m.
Clinic Intro
Price, Melissa Kucharczuk, Bethany Johnston and
Brittany Watkins qualified for nationals in 2009
12:45 p.m.
Warm up/ Base Line Set
and finished 12th at the NCAA meet while setting
a school record.
1:25 p.m.
Group Training I
_______________________________________________
2:05 p.m.
Group Training II
_______________________________________________
In the 2011-2012 season, IUP senior Jackie Hynson won her first NCAA title in the 200 butterfly in
2:35 p.m.
Stroke Essentials
3:15 p.m.
Camp Relay Challenge
3:30 p.m.
Cool down/Goodbye
a time of 1:58.84. The IUP women garnered 8 AllAmerican accolades and placed 15th in the nation
under Coach Villa’s direction. In 2010, Chris was
recognized as PSAC Coach of the Year.
The swim team also excels in the classroom,
consistently placing athletes on the dean’s list
and achieving 4.0 GPAs.
EAR INFECTION _________________________
BLOOD PRESSURE _______________________
BLEEDING / CLOTTING ___________________
ASTHMA _______________________
DIABETES ______________________
CHICKEN POX___________________
MEASLES
3 DAY_____
9 DAY _____
HEART DEFECT MURMUR _________________
MUMPS ________________________
CONVULSIONS __________________
____________________________________________________
PHYSICIAN NAME
___________________________________________________________________
PHYSICIAN PHONE NUMBER
_______________________________________________
INSURANCE COMPANY
Medical Insurance
IUP does not provide medical insurance for
clinic participants. In the event of illness or injury
requiring treatment, hospitalization, and/or surgery,
the family’s medical insurance must be used.
INSURANCE POLICY NUMBER
PHONE NUMBER
I HEREBY CONSENT TO ANY AND ALL HEALTH SERVICES NECESSARY TO THE
INDIANA REGIONAL MEDICAL CENTER’S EMERGENCY ROOM.
I GIVE
AUTHORITY AND POWER TO ANY SUCH PHYSICIAN/SURGEON TO RENDER ANY
AND ALL HEALTH SERVICES THAT MAY BE DEEMED NECESSARY OR ADVISABLE.
I AUTHORIZE THE IUP CAMP DIRECTOR AND/OR STAFF TO ACCOMPANY THE
STUDENT AND SIGN PERMIT FORMS REQUIRED BY THE MEDICAL CENTER.
I UNDERSTAND IN CASE OF SERIOUS ACCIDENT OR ILLNESS EVERY EFFORT WILL
BE MADE TO CONTACT ME. I UNDERSTAND I WILL BE RESPONSIBLE FOR ANY
COSTS OR CARE NOT PROVIDED. I UNDERSTAND THERE IS RISK OF INJURY FOR
MY SON OR DAUGHTER WHILE PARTICIPATING IN THE CAMP AND I HEREBY
VOLUNTARILY ASSUME ALL RISKS ASSOCIATED WITH PARTICIPATION AND
AGREE TO EXONERATE AND RELEASE IUP, IT’S AGENTS, SERVANTS, TRUSTEES,
AND EMPLOYEES FROM ANY AND ALL LIABILITY.
____________________________________________
PARENT / GUARDIAN SIGNATURE
DATE