Application for the THE LINEBACKER SCHOOL, July 6, 7, 8th, 2008
Name:__________________________________________________________________
Address:________________________________________________________________
City:___________________________State:____________Zip Code:_______________
Phone# ( ) ___________________________________DOB_________________
School: _____________________________________Grade_____________as of Sept. 2008
E-Mail:________________________________________Shirt Size:__________________
Location: CURRY COLLEGE
JULY 6, 7, 8th, 2008
To insure your reservation, a $250.00 fee is required with your application.
If sending three players from one team fee is $225.00 each
If sending five players from one team fee is $200.00 each
____ place check here if needed to rent a helmet for an additional $35.00
Please send checks to:
John Bandini
No. Waltham, MA 02455-0158
Choose one defensive position: Please check one
___Inside Linebacker ___Outside Linebackers
List Weakness:_____________________________________________________________
How did you hear about the Linebacker School?__________________________________
Form 2008
PLEASE PRINT 2 Pages, complete both forms and forward.
Medical Release
The named player has my permission to participate in this program. In case of an emergency,
I understand that every attempt will be made to contact me. If contact is unsuccessful, I give permission to the attending training staff to render treatment to the participant, including hospitalization. Any expense arising from injury is the responsibility of the person signing below. I hereby authorize the staff of the LINEBACKER SCHOOL to provide care that includes routine diagnostic procedures (i.e. x-rays, blood & urine tests) and
medical treatment as necessary to my minor son/daughter.
PARTICIPANTS NAME:_____________________________________________________
Please list any physical conditions that the athletic trainer and staff should be aware of
( allergies, recurring illnesses, disabilities, chronic illness, asthma, insect allergies, etc.)
List Condition(s): ____________________________________________________________
___________________________________________________________________________
Month/Day/Year of most recent Tetanus: __________________________________________________
If more than ten years ago, a booster shot is recommended.
I agree to indemnify and hold harmless the staff of the LINEBACKER SCHOOL and Curry College its agents and employees, from any and all liability in connection with these activities.
Parent/Guardian Signature:________________________________Month/Day/Year:_________________
Emergency Notification: __________________________________Tel# ( )_____________
Pager #___________________________Cell # ( )__________________________
Please List your health insurance carrier and policy # below:
Ins. Co. _____________________________________Policy #___________________________
All players shall submit a physical examination form from their doctor with the application prior to the school.
ALL INFORMATION ABOVE MUST BE COMPLETED TO ATTEND CLINIC. Form 2008
