THIS IS AN OLD FORM -- PLEASE GO TO WWW.BRONCOATHLETICS.COM AND CLICK ON "CAMPS" TO ACCESS THE 2006 FORMS
Emergency Information | Release of Liability | Medical Consent Release | Payment Information
• Child's Information
Camper’s Name Female Male
Birthdate Age Home Address City
State Zip
Grade School Name
School Address City Zip
T-shirt size (adult sizes) small medium large x-large
• Emergency Information (top of page)
Parent/Guardian Name
Home Phone Work Phone
Cell Phone
Emergency Contact
Medical Insurance Provider
Company Policy # Expiration Date
Please list any medical conditions, disabilities or allergies
• Release of Liability (top of page) (One form per child, form must be signed)
I give permission for my child to participate in the referenced activity/activities, hereby assuming full responsibility for all risk of injury or loss which may result from my child’s participation in: Baseball Camp Basketball Camp Tennis Camp Volleyball Camp Soccer Camp and hereby agree to hold harmless and indemnify the State of California, California State Polytechnic University, Pomona, the trustees, officers, agents, faculty, staff, volunteers and students against all claims, demands, suits, judgements arising out of or in connection with the aforementioned activity.
• Medical Consent Release (top of page) (One form per child, form must be signed) As the parent/legal guardian of , I request that in my absence the above named CHILD if required be admitted to any hospital or medical facility for diagnosis and/or treatment. I request and authorize physicians, nurses, dentists and staff, to perform any diagnostic procedures, treatment procedures, and operative procedures to the above named individual. I have not been given any guarantee as to the results of any treatment if performed on the above name individual. I hereby accept any financial responsibility for any and all medical treatment necessary to be administered to the above named CHILD in the event of an accident, injury, sickness, etc. Any representative of California State Polytechnic University, Pomona is designated to act in my behalf until I have been contacted. I have understood the terms and conditions of the Release of Liability and Medical Consent/Release
Form and am signing on behalf of my child
Parent/Guardian (Print)
___________________________________________________________ Date Parent/Guardian Signature
Are you a Cal Poly Pomona employee? Yes No
Department Extension
• Payment Information (top of page) (If paying by credit card, all information requested must be complete)
Make checks payable to: Cal Poly Pomona Foundation Mail forms & payments to: Sports Camp Coordinator Cal Poly Pomona Athletics 3801 West Temple Ave. Pomona, CA 91768
If paying by credit card please fill out the information below:
Name on Card Expiration Date
Card Type (visa/mastercard only) American Express Mastercard Visa Card
Card Number
Security Code (the last three digits on the back of your card near your signature.)
Amount to be Charged
______________________________________________________________ Date Signature THIS IS A SECURE SERVER—fill this form out completely and mail to: Sports Camp Coordinator, Cal Poly Pomona Athletics 3801 West Temple Avenue Pomona, CA 91768. This form must be accompanied by, at least, a $50 deposit per camp. The deposit is NON-REFUNDABLE unless the camp is cancelled. You may pay by check, money order, cashiers check, or credit card (no cash please).
