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

Mail application and non refundable deposit check to:

High Performance Distance Academy c/o Runabout Sports
801 University City BLVD, Suite one Blacksburg, VA 24060

Make check out to: High Performance Distance Academy
Deposit amount: $75.00. Final payment mailed when camp packet is received (in July).

Last Name ______________________ First _____________________Age _____ Sex _____ School ________________________________
Year in School (Fall ’13) ____________ 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) Session I or II: ______ Both: _______
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 2013 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. Please initial if you understand and agree to: _____________

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. Please initial if you understand and agree to: _____________

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: __________ Deposit Check # ________ AMT: _______ Date: __________ Final Payment

Call 540-552-9339 or 540-230-2154 for information. Camp date: July 8th-13th, 2013 or July 22nd-27th, 2013