Application for the The Quarterback Technique Clinic: June 22, 23, 24th, 2008
Name:__________________________________________________________________
Address:________________________________________________________________
City:___________________________State:____________Zip Code:_______________
Phone# ( ) ___________________________________DOB_________________
School: _____________________________________Grade_____________as of Sept. 2008
E-Mail:________________________________________Shirt Size:__________________
Fee:
To insure your reservation, a $185.00 fee is required with your application.
No Helmet Rentals
Please make checks payable to: John Bandini
No. Waltham, MA 02455-0158
List Weakness:_____________________________________________________________
Equipment Needed: Helmets & Cleats.
How did you hear about The Quarterback Technique Clinic?_________________________
Medical Release
The named player has my permission to participate in this program. In case of an emergency,
I understand that every attempt will be made to contact me. If contact is unsuccessful, I give permission to the attending training staff to render treatment to the participant, including hospitalization. Any expense arising from injury is the responsibility of the person signing below. I hereby authorize the staff of The Quarterback Technique Clinic to provide care that includes routine diagnostic procedures (i.e. x-rays, blood & urine tests) and
medical treatment as necessary to my minor son/daughter.
PARTICIPANTS NAME:_____________________________________________________
Please list any physical conditions that the athletic trainer and staff should be aware of
( allergies, recurring illnesses, disabilities, chronic illness, asthma, insect allergies, etc.)
List Condition(s): ____________________________________________________________
___________________________________________________________________________
Month/Day/Year of most recent Tetanus: __________________________________________________
If more than ten years ago, a booster shot is recommended.
I agree to indemnify and hold harmless the staff of The Quarterback Technique Clinic and the City of Waltham, its agents and employees, from any and all liability in connection with these activities.
Parent/Guardian Signature:________________________________Month/Day/Year:_________________
Emergency Notification: __________________________________Tel# ( )_____________
Pager #___________________________Cell # ( )__________________________
Please List your health insurance carrier and policy # below:
Ins. Co. _____________________________________Policy #___________________________
All players shall submit a physical examination form from their doctor with the application prior to the school. Please Print Form, Complete and Mail to Address Above.
ALL INFORMATION ABOVE MUST BE COMPLETED TO ATTEND CLINIC. Form 2008
