High school running camp register. | Ultimook Running Camp

Which session are you registering for:*

First Session, July 30 to Aug. 5th
Second Session, Aug. 6th to Aug. 12th

I'm registering as:*

Individual Camper: $425/camper
Group Camper (2-4 campers from same school): $395
Team Camper (5 or more from same school): $345
Not sure yet (rate can be determined later by how many of your teammates sign up):

How do you plan on paying for camp?*

I'm going to pay my deposit and pay the balance at camp check-in via check or cash.
I'm going to pay my deposit and authorize you to charge my credit card 1-2 weeks prior to camp.
I'm going to make a full payment for camp now.

Athlete Registration

Name*

First Last

Gender*

Male
Female

Age (at time of camp):*

Grade (Fall of 2017)*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone Number:*

Campers Cell Phone:

Email Address*

School Name:*

If you are coming as a group or a team, please be sure that the name of your school is consistently the same between all your teammates. This will ensure that you'll be eligible for the group/team discount.

Coach's Name:

T-shirt Size:*

Dietary Restrictions

Vegetarian
Gluen free

Parent's Information

Parent's Name #1*

First Last

Phone #1*

Email #1*

Parent's Name #2

First Last

Phone #2

Email #2

Special information we should know about your son/daughter:

Running History

Please give us an idea what kind of runner you are at the time of camp so we can individualize your training and place you on the appropriate camp team. It is not necessary to have times for all of the distances listed below, please just input times for distances you've ran. Don't worry, we will not separate athletes from the same school.

800m P.R.

1500m P.R.

3000m P.R.

3000m P.R. Cross Country

5000m P.R. Cross Country

Other P.R.

list distance & time

How many miles do you plan on running per week in the summer prior to camp?

What are your Cross Country goals for the fall of 2017?

Emergency Contact Information

Name*

First Last

Relationship*

Phone*

Health & Medical Info/Liability Release

Medical Insurance Company:*

Policy Number:*

Doctor's Name

First Last

Doctor's Address

City State

Doctor's Phone Number

In case of emergency, is there anything camp staff or the doctor should know?

Do you suffer from Medical Allergies?*

No
Yes (specify below)

Do you suffer from Food Allergies?*

No
Yes (specify below)

Do you suffer from any of the following?

Heart trouble
Diabetes
Skin trouble
Fainting Spells
Lung Trouble
Ear Trouble
Sinus Infection Allergies
Insect Bite Trouble
Sickle Cell Disease

If so, please explain in the box below:

Are you trying to lose or gain weight?

No
Yes

Do you limit or carefully control what you eat?

No
Yes

Has a doctor ever denied/restricted your participation in sports for any reason?*

No
Yes

Please explain:

Please explain any other health problems:

Do your require prescribed medicine of any sort. If so, this will need to be administrated by the head trainer.*

No
Yes

Please list prescribed medicine here:

All prescribed medicine must be checked into the head trainer in originally prescribed bottles upon check in at camp.

Medical & Liability Release:

For Parent or Legal Guardian only.

Registrants full name:*

Please type full name of athlete here.

Please read the following waiver and agreement carefully:*

I understand the inherent risks involved in participating in the rigorous physical activity required of an outdoor running camp and I assume full liability of hazard and risk for my child during this year’s Ultimook Running Camp. I hereby authorize staff and agents of The Ultimook Running Camp to act for me according to their best judgment in any emergency and give permission for hospital or medical center staff to administer any necessary treatment immediately to my child should he/she be sick or injured while attending The Ultimook Running Camp. I do not hold anyone involved in The Ultimook Running camp, or its respective staff responsible for any injury as a result of my child’s participation in the Ultimook Running Camp.

I agree to the above waiver.

Electronic Signature*

By entering my full name below, I assert that I have reviewed and agree to the above waiver by which I have selected above.

Electronic Signature*

By entering my full name below, I authorize the remaining balance of camp to be charged to my credit card 1-2 weeks prior to camp as indicated by my selection above.

Note: When finished click "submit" below. Then choose your route of payment on the right and click to place in the shopping cart. You can then finalize your registration by entering your credit card information into our secure system. Please be aware that your credit card statement will show "Oregon Coastal Flowers LLC" as the vendor. This is our main business and allows us to charge credit cards economically. Please make a mental note to associate "Oregon Coastal Flowers LLC" with the most beautiful setting available for a running camp.