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This form must be completed and submitted with payment before you will be allowed to participate.

Registration Form:

Name: __________________________________________________________ 

Male: _____ Female: _____       T-Shirt Size:     S      M      L      XL

Email address: __________________________________________________________

Home Address: __________________________________________________________


City/State: __________________________________________________________

 Zip: __________________

Parents’ Name:  __________________________________________________________

Home Phone:    __________________________________________________________

Athlete’s Cell Phone:  __________________________________________________________

Emergency Phone and Contact Person:  __________________________________________________________

Age: _______           Birth Date: __________________________

HS Graduation Date: __________________

School Name: __________________________________________________________________________

School Coach: _________________________________________________________________________

What is your PR (personal record): ______________

Informed Consent and Release
I hereby grant permission for myself / child to attend Pure Sky Vault Club. I verify that I / my child has had a physical exam in the past year and is capable to participate in the activities related to pole vaulting. I agree to indemnify, hold harmless, and defend all coaches and staff of Pure Sky Athletics, USA Track and Field, Pure Sky Athletics, their agents, employees and sponsors from any and all liability for injury to myself and/or my child. I understand that track and field, and in particular pole vaulting and many of its related activities are potentially dangerous and could pose risk of injury. Should medical attention be necessary, I hereby authorize any physician or trainer selected by the club personnel to conduct medical or surgical procedures. In addition, I hereby grant permission for Pure Sky Athletics to use any photographs or videotape of club related activities for the purpose of advertising or educational materials development. I HAVE READ AND UNDERSTOOD, AND AGREE WITH THE INFORMED CONSENT AND RELEASE OUTLINED AS IT RELATES TO MYSELF/SON/DAUGHTER.

Participant Signature:  __________________________________________________________________

Parent / Guardian Signature: ______________________________________________________________