2016-Falcon-Pride-Camp-Form - Pennsbury High School Wrestling

at Pennsbury HS
June 20-June 24, 2016
Pennsbury High School West Campus Falcon Gym
Open to all Elementary through High School
Wrestlers with varying ability levels
Wrestling Camp
at Pennsbury HS.
Attn: Coach Phil Kealy-Wrestling Coach
608 S. Olds Blvd
Fairless Hills, PA 19030
Jason Bing-3x PIAA Qualifier
at Pennsbury High School
CAMP COACHES:
PHIL KEALY
Head Wrestling Coach-Pennsbury HS
TIM ORTMAN & MIKE HERMANN
Assistant Wrestling Coaches-Pennsbury HS
GUEST CLINICIANS TO FOLLOW
CUT HERE
Coach Phil Kealy
CAMP INFO
DATES: June 20-June 24, 2016
TIME:
•
6-12 Camp 8:00am-11:00am
•
K-5 Camp 12:00pm-3:00pm
LOCATION: PHS West Campus Falcon
Gym
BRING:
CUT HERE
2016 WRESTLING CAMP @ PENNSBURY HS
REGISTRATION FORM
NAME: ____________________________________________________
ADDRESS:_________________________________________________
CITY: _____________________ STATE: _____ ZIP:_____________
PHONE: __________________
SCHOOL: ____________________
CAMP (CIRCLE ONE):
6-12 Camp
K-5 Camp
•
Wrestling & Running Shoes
T-SHIRT (CIRCLE ONE): YS YM YL AS AM AL AXL AXXL
•
Headgear
•
T-Shirt & Shorts
•
Water/Drink Bottle
EMERGENCY CONTACT: ___________________________________
CONTACT PHONE: ________________ RELATION: _____________
PHYSICIAN CONTACT:______________________________________
PHYSICIAN PHONE: ________________
COST: $120 per camper
MAKE CHECKS PAYABLE TO:
PARENTS OF PENNSBURY
WRESTLING
MAIL FORM & CHECK TO:
WRESTLING CAMP @ PENNSBURY HS
ATTN: PHIL KEALY-WRESTLING
COACH
608 S. Olds Blvd
Fairless Hills, PA 19030
MEDICAL CONCERNS (if any): ______________________________
I hereby acknowledge that participation in this sports camp and related activities is at the sole discretion
and judgment of the parent or guardian and involves an inherent risk of physical injury. I, on behalf of my
son/daughter, hereby assume all such risk.. I hereby release and agree to hold harmless the Pennsbury
School District, its School Board, students, employees and clinicians from claims, actions, damages and
liabilities for personal injury or damage relating to or arising out of any sports camp activity except where
the injury or damage is caused by the gross negligence of the school’s employees. I understand that this is
NOT a Pennsbury sponsored camp and the District tax identification number will not be provided for any
reason including child care deduction purposes.
I, _________________________________________am the parent/guardian of the camper named above. By
signing below I hereby give my permission for the Wrestling Camp at Pennsbury HS to provide for any
needed medical treatment for my son/daughter while he/she is attending. I specifically give my permission
for necessary emergency care to be given to _______________________________________(name of
camper). I attest that my son/daughter had a physical within the last 12 months and the physical disclosed
no medical conditions, other than those listed on this waiver, that would make participation in this sports
camp a risk.
Signature of Parent/Guardian ___________________________________________
Date:_______________