High Performance Distance Academy Application
TWO PAGE APPLICATION
Information must be completed for acceptance to camp.
Please PRINT CLEARLY.


Mail two page application and deposit check to:
High Performance Distance Academy
c/o Runabout Sports
801 University City Boulevard, Suite 1
Blacksburg, VA 24060

Make check out to: High Performance Distance Academy

Last Name ______________________ First _____________________

Age _____  Sex _____  School ________________________________

Year in School (Fall ’06) ____________ Coach ___________________

PR’s: 1600 meters ________3200 meters _________ Avg. Mileage/ week ______

Parent/ Guardian Name: _____________________________________________

Address ________________________________________________________

City ______________________ State __________ ZIP _________________

Phone _______________(O) _________________ E-mail _______________________________

Shirt size:    S   M   L   XL   (circle shirt size desired)

Roommate Request (We'll try to honor request): _____________________________________

MEDICAL INFORMATION

Emergency Contact NAME _______________________ Phone _____________________

Physician’s Name ___________________________ Physician’s Phone ______________

Any known medical conditions (ex.: asthma, allergies, diabetes, injuries)

___________________________________________________________________________

Date of last tetanus immunization _______________ Medication camper will bring

_________________________________________________________________________

Will camper self administer medication? _________________________

INSURANCE INFORMATION

Family Medical Insurance Company ___________________________________________

Policy Holder's Name: ___________________________________________________

Policy Number ________________Policy Group ____________________________

PARENTAL CONSENT STATEMENT

We (I) hereby request that you accept the application of __________________________ in the 2006 High Performance Distance Academy during the dates set in this application and in consideration of this application, we (I) hereby release the High Performance Distance Academy and all claims on accounts of any injuries which may be sustained by our (my) child as a result of any such activities. Furthermore, we (I) certify that within the past year my child has had a physical examination and is physically able to participate in sports activities. In the event of illness or injury, we (I) give my consent for medical treatment and permission to hospitalize, secure proper treatment, and order injections, anesthesia, and/or surgery.
I/ We the undersigned hereby acknowledge, understand and accept liability that the High Performance Distance Academy is a privately run sports camp and is not operated by or through Virginia Tech. The camp is neither sponsored, controlled, nor supervised by Virginia Tech, and release the aforementioned corporation from liability. I/ We also understand that Runabout Sports, L.L.C. directs and controls High Performance Distance Academy . James DeMarco is the Academy director for Runabout Sports, L.L.C.

I/ We waive, release, and discharge High Performance Distance Academy, James DeMarco, Runabout Sports, L.L.C., Virginia Tech, and the aforementioned staffs, officers, agents, employees, representatives, successors, and assigns from any and all liability claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, personal injury or property damage that may be sustained or occur during the participation in camp activities or while at camp.

Any camper who exhibits unacceptable behavior will be immediately dismissed from camp without a refund. Dismissal will be at the discretion of the camp director.


Parent’s Signature _______________________________Date _____________________

For Office Use Only: Check # ________ AMT: _______ Date: __________ 
                               Check # ________ AMT: _______ Date: __________