Pitching Clinic Registration Form

Name_____________________________________________         Grade _________________________

Mailing Address _______________________________________________________________________

____________________________________________________________________________________

School_____________________________________________        Email _________________________

Parent/Guardian ____________________________________         Contact # ______________________

Allergies _____________________________________________________________________________

Medication Instructions if needed ___________________________________________________________

_____________________________________________________________________________________

Other Concerns ________________________________________________________________________

_____________________________________________________________________________________

Other Emergency Contact Name and Number_________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

I __________________________ give,  ________________________________ permission to participate in the

Salem Pitching Clinic. I understand that an injury may occur and will not hold Salem University Responsible. In the

event of an injury I give the clinic permission to care for my child within necessary means.

 

Parent/Guardian Signature _______________________________________________________________

Date _________________________

 

Return to:

Coach Steve Potts

223 West Main Street

Salem, WV 26426