Registration Form Midland University Midland Warrior Football … · 2016. 5. 23. · DL Coach &...
Transcript of Registration Form Midland University Midland Warrior Football … · 2016. 5. 23. · DL Coach &...
DL Coach & Special Teams Coordinator
Sam Cummings
Camp Coordinator
1 Day Indy
Camp
At
Midland University’s
Heedum Field
Monday July 25th
9 AM to 1 PM
Midland University
Football
Midland Warrior Football Staff
Head Football Coach
Jeff Jamrog 1st Year Midland University Head Football Coach
27 years of college coaching experience
13 years on staff at University of Nebraska
Nebraska Husker football player 1983– 1987
Mount Michael High School Graduate
Midland University Football Staff
Ryan Williams - Midland Off. Coord & QB’s Coach
Played QB at North Dakota State 1997-2000 (Capt.)
Jamison Bisch– Midland Def. Coord & LB’s Coach
Played DB at UW-River Falls 2003-2008 (Capt.)
Mike Caputo - Midland Offensive Line Coach
Played Center at Nebraska 2007-2011 (Capt.)
Jack Riggins - Midland Wide Receivers Coach
United State Naval SEAL Officer 1998-2016
PJ Smith - Midland Defensive Backs Coach
Played Safety at Nebraska 2008-2012
Tom Brinkman - Outside Linebackers
Josh Caraway - Defensive Line
Matt Purdom– Tight Ends
Registration Form *** Please register for the camp at our on line camp website registration at
http://www.midlandufootballcamps.com/ If you are unable to register on line use the paper format below
To be completed by parent or legal guardian. Please print clearly. Be sure to fill in all sections including signatures. Make sure to fill out one registration form per camper. Please return registration, waiver and payment to program address below.
Name_____________________________________________________________
Address__________________________________________________________
City_______________ St______ Zip__________________________________
Phone #__________________________________________________________
E-mail:___________________________________________________________
Camper, Date of Birth______________________________________________
Parents/Guardians Name__________________________________________
Ins. Company ____________________________________________________
Ins. Policy #_______________________________________________________
Emergency contact ________________________________________________
Emergency contact # ( )________________________________________
Individual Profile
Height___________ Weight____________ Age________________________
High School _______________________________________________________
Fall ’16 Grade _________________ T-Shirt Size________________________
Off Position_______________ Def Position____________________________
Primary Position ____________
Payment Information $35 Per Camper
*Make checks payable to Midland University Football*
THIS IS A PADDED CAMP
Please bring football cleats, helmet, shoulder pads, and mouthpiece
Midland University Football 900 N. Clarkson
Fremont, NE 68025
Office Phone: 402-941-5366
Fax Number: 402-721-9406
E-mail: [email protected]
1 Day Indy Camp Waiver Information
Parental Consent, To Whom It May Concern: The undersigned does hereby give permission for our (my) child__________________________________ ______________________________________to attend and par-
ticipate in the Midland University Football Summer Camps at given locations during the summer months of June 1—July 31, 2016. We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to
the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medi-cal Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician
or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall
assume all transportation costs. The undersigned does also hereby give permission for our(my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Midland University. I
give permission for any pictures or videos taken during the confer-ence to be used at the discretion of Midland University, the students, faculty, staff, or other representatives. I release and forever dis-charge Midland University, their agents an servants, successors and assigns, directors, trustees, officers, employees, and other represent-
atives against loss from any and all present or future claims, de-mands or actions in law or in equity that may hereafter be made or brought by me or my child, by anyone on behalf of me or my child, or by anyone else on their own behalf for damages or any other legal or
equitable remedy on account of any injury, illness, physical condition, inconvenience, or loss sustained by my child during the planned activ-ities for which my child is registering to participate.
Parent/Guardian Name_________________________ Parent/Guardian Signature______________________ Date of Signature _________ Please list any medical conditions that may affect participation:
_____________________________________ Please list any medications the camper will bring
____________________________________ Can first aid such as ice packs and band aids be administered?:
____________________________________ Can over the counter medicines such as Tylenol, antacid or triple antibiotic be administered?:
_____________________________________ Please list any known allergies:
_____________________________________
Midland University 1 Day Individual Camp is a
great opportunity for all Nebraska and
surrounding area high school foot-
ball talent to put their skills on
display. The camp will be held on
the campus of Midland University
at the Warriors home stadium,
Heedum Field. This is an opportunity
to show off your talent in front of the
Midland University coaching staff. Mid-
land’s staff has a combined 60 years of
coaching experience at both the high school and col-
lege levels. While at camp, you will par-
ticipate in the same drills that the
Warriors use to prepare for game
day. These high intensity drills pro-
mote competition and will show
who wants to win! The area’s best
talent will be in Fremont to display
their talent. Don’t miss out on this great
opportunity to showcase your talent to
Warrior Football
Over 4 Hours on campus with Midland Football Program
Verified Testing for the recruiting process
- 40 yard dash
- Vertical Jump/Broad Jump
- Pro Agility
- L Drill
Verified Measurements
- Height
- Weight
Participate and learn high level football drills from the Mid-
land football staff
Opportunity to Compete against some of the areas top
competition in Nebraska
Complimentary Midland University Football T-Shirt
8:00am - 9:00 am Check-In 9:00am - 12:30 pm Testing Off/Def Practice Group Drills 12:30pm - 1:00pm Awards & Closing
Shoulder Pads
Helmet
Mouth Piece
Football Cleats
Camp Schedule for Monday July 25th
Included during the camp
Pads Needed for Camp