When: Saturday, February 6, 2010 Time: Instruction 10:00am 1:30pm. Where: Santa Clara University Music& Dance building Dance Studio A

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1 Join the Santa Clara Cheerleaders for a Special One Day Clinic! Perform at halftime of the SCU Women s Basketball game Supervised instruction* from SCU Cheerleaders and staff (3:1 child to instructor ratio) *AACCA safety certified instructors Learn age appropriate stunts, dance choreography, and official Bronco crowd cheers! Post game autographs with Cheer Team & Women s Basketball team! Photo Opportunity w/ Cheer & Bucky the Bronco When: Saturday, February 6, 2010 Time: Instruction 10:00am 1:30pm Lunch noon 1:00pm Game begins at 2:00pm *Halftime performance approx 3:00pm Where: Santa Clara University Music& Dance building Dance Studio A Who: Girls and Boys, Ages 7 14 Sign in: studio A Pick up: 1:30pm@Leavey Center For more information visit Or contact: SCUCheer@gmail.com

2 Join the Santa Clara Cheerleaders for a day clinic! Participants will perform at halftime of the SCU Women s Basketball game the same day!!! When: Saturday, February 6, 2010 Time: 10:00 am 1:30 pm; Game begins at 2:00 pm Photo opp. with SCU Cheerleading team and Bucky the Bronco before game! Where: Santa Clara University Music & Dance building Dance Studio A Who: Boys and Girls Ages 7 14 (All Skill Levels!) Fee: $ 65 (Includes instruction, lunch, 1 parent game ticket, HT performance & Photo op with Bucky and SCU Cheer) Pre register by Monday, January 25 th and receive a FREE shirt! (After January 25 th, participant shirts will be $10 each) Payment Methods pick one: Check # (Preferred method; payable to Santa Clara Athletics) Cash (In person sign ups please do not send cash) Credit Card Visa or MasterCard: EXP: / Cardholder s Name: Security Code: Cardholder s Signature: Total: $ Registration Information* required please print Participant Name Gender Skill Level T Shirt Size KIDS S M L ADULT S M L Address City State Zip Phone E mail Print a copy On line: SantaClaraBroncos.com/Cheer Mail to: Santa Clara Athletics Attn: SCU Cheer 500 El Camino Real Santa Clara, CA *Include liability form for complete registration Inquiries? Please E mail: SCUCheer@gmail.com for more information

3 SANTA CLARA UNIVERSITY YOUTH CHEER CLINICS MEDICAL HISTORY/ INSURANCE INFORMATION CONSENT/RELEASE OF LIABILITY Each participant must have this form on file before participating in any clinic activities. Participant Name: Last First Middle Birthday: Age: Sex: Parent or Guardian: Home Address: Number/Street City St. Zip Home Phone: Work Phone: Address: If not available in an emergency, please notify: 1. Phone: Relationship: 2. Phone: Relationship: HEALTH HISTORY Has/Does the participant: If yes, please explain. 1. have a current injury/illness/infectious disease? No Yes 2. have a chronic or recurring illness/condition? No Yes 3. ever been hospitalized? No Yes 4. ever had seizures/convulsions? No Yes 5. have diabetes? No Yes 6. have asthma? No Yes 7. have allergies/ No Yes 8. had mononucleosis in the past 12 months? No Yes Medications Currently Being Taken: (include both over-the-counter and prescription medications) This participant takes NO medications on routine basis. This participant takes medications as follows: Med. #1 specific times taken reason for taking dosage. Med #2 specific times taken reason for taking dosage. Attach additional pages for more medications. Please list any food allergies of this participant: More on back side

4 Please list any restrictions for this participant while at the clinic. INSURANCE INFORMATION All participants must have their own medical/accident insurance coverage and notify the camp/clinic of any changes or cancellations. Medical Insurance Company: HMO PPO Policy Number: Group Number: Number of Subscriber: Subscriber s ID Number: Claims/Billing Address: Number Street City State Zip Phone If HMO or PPO, who is your primary care physician? Primary care physician phone: Parent s/guardian Consent: This health history for is correct as far as I know, and has permission to engage in all prescribed camp activities, except as indicated as restrictions on front side of document. In the case of any emergency where I cannot be reached, I hereby grant permission to Santa Clara University s Sports Camp/Clinic Program staff, assigned physicians and/or their consulting physician to render to my son or daughter, any treatment, medical or surgical care that they deem reasonably necessary to the ensure the health and well-being of my child as named above. I will be financially responsible for any medical attention needed during the Clinic or resulting from an injury received at the Clinic. I also hereby authorize the athletic trainers at Santa Clara University Sports Camp/Clinic to render to my son, daughter, any preventative, first aid, rehabilitative or emergency treatment that they deem reasonably necessary to the health and well-being of my child as named above. Parent/Guardian Signature Date Acknowledgment of Risk and Release from Liability Participation in the Clinic entails risk of serious and/or mortal injury and disability to my child and that I am allowing my child to participate with full knowledge of those risks I certify that my child is adequately healthy to participate in the Clinic and will advise SCU of any medical problems that may effect my child s participation in the Clinic. I hereby assume all risks associated with participation in Santa Clara University Sports Camp/Clinic and agree to hold harmless Santa Clara University, its Sports Camp/Clinics, its directors, officers, employees, agents, representatives, coaches, volunteers, and athletic trainers from and against any and all claims, demands, losses or liability of any kind or nature which may arise in connection with injuries suffered, to my child while participating in Santa Clara University Sports Camp/Clinic. I HAVE READ THIS CONSENT FORM AND RELEASE OF LIABILITY AND UNDERSTAND ITS TERMS. I EXECUTE THIS CONSENT VOLUNTARILY WITH FULL KNOWLEDGE OF

5 ITS SIGNIFICANCE, KNOWING THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. Parent/Guardian Signature Date