Registration Form
Helena Pole Vault Camp 2010
Pole Vault Registration 2010
Your Name *
Address *
City, State, Zip *
School *
Home Phone *
Age *
T-Shirt Size *
Personal Best in Pole Vault
Emergency Contact Name *
Emergency Phone *
Family Doctor
Doctor Phone
Health Insurance Company *
Any Medical Conditions
June 21-22
 Yes 
June 23-24
 Yes 
June 25-26
 Yes 
June 28-29
 Yes 
June 30 - July 1
 Yes 
Read disclaimer below before signing *
 Yes 
Signature of Athlete *
Date *
Signature of Parent/Guardian *
Date *
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By Signing this document, I hereby authorize the staff of the Helena Pole Vault Clinic the right to consent any medical treatment needed for my son/daughter. I hereby state that I or my son/daughter have had and passed a physical examination in the past year and that I am sure that he/she is in good health in which to compete in the rigors of the events in the camp. I hereby assume all responsibilities for myself or my son/daughter and hereby hold FREE the Helena Pole Vault Clinic harmless for all accident, injury, illness, death, or damage occurring by reasons of the clinic.