ATHLETE INFORMATION RETURN THIS FORM TO DSU SPORTS ACCELERATION WITH A $150 DEPOSIT. SEE CHECKLIST FOR ALL REGISTRATION FORMS REQUIRED. Last Name: ______________________________First Name: __________________________M.I._________ Birth Date: _____/______/______ Gender M or F Address: _____________________________City: _______________State: ________Zip:________________ How Did You Hear About Our Program? ______________________________________________________ Have you ever trained with us? When? _______________________________________________________ If yes, what level did you do? _____________________________ Phone: (______)_____________ Cell Phone: (_____)_____________ E mail Address: _____________________________________ Parents Email Address:____________________________ EMERGENCY CONTACT: ________________________________ EMERGENCY PH#:_______________________ Fathers Full Name: _______________________________ Address (if different):____________________________ Mothers Full Name: ______________________________ Address (if different):____________________________ Sport #1 School ____________________ Year in School ____________________ Position(s) ____________________ Coach ____________________
Sport #2 ___________________ ___________________ ___________________ ___________________
Sport #3 ____________________ ____________________ ____________________ ____________________
Sport #4 ___________________ ___________________ ___________________ ___________________
PROGRAM CHOICE (Please Circle One)
1) Deposit __________________ A minimum deposit of $150.00 is required to guarantee a training slot for summer session. Any balance is due upon the athleteâ€™s first workout to receive the PAID IN FULL DISCOUNT (10%). If unable to completely pay for the program in advance, balance will be due on July 1, 2009 (without 10% discount).
2) Payment Method: ( ) Check/Cash
( ) Visa / MasterCard / Discover
Name on Credit Card: ______________________________ V Code (3 Digit number on back):____________ Credit Card #: _____________________________________ Expiration Date: _________________________ I understand that I am responsible for fulfilling the above payment arrangements set forth by DSU Acceleration Sports Training. Signature of Participant (or parent if a minor)
Informed Consent 1. My participation is voluntary and I may withdraw from the evaluation or program at any time. The benefits associated with my participation include information regarding my personal state of fitness and the increase of my physiological knowledge. 2. I HEREBY CONSENT TO and PERMIT the DSU Sports Acceleration Training staff to use the data obtained in report or publications, but my identity will not be associated with such reports unless I have given specific permission to do so. 3. I understand that these evaluation(s) should not result in physical injury to me. However, I acknowledge the following: In the event of physical injury resulting from the evaluation procedures, equipment usage of equipment testing, initial first aid will be provided. If further Medical attention is needed I must look to my own health insurance policies for further medical assistance. 4. I understand that the DSU staff is relying on all information provided by me regarding my medical history and condition before allowing me to participate in any evaluation or program. I certify the information to be true and correct. ___________________________________________ Signature of Participant
Permission to Provide Medical Treatment Agreement I HEREBY give my permission for my son/daughter, ___________________________________ to undergo medical treatment for any injury or illness he/she may sustain or acquire while engaged in any training at DSU Sports Acceleration Training. I understand that the personnel of DSU Sports Acceleration Training will perform only those procedures, which are within their training, credentialing, and scope of professional practice to prevent, care for, and rehabilitate injuries. In the event that more serious medical procedures are required, such as surgery or other invasive procedures, I understand that attempts will be made to contact me for my consent. I understand that if my child suffers a potentially life threatening injury or illness, and in the event I am unable to be contacted within a reasonable period of time, that I authorize any duly licensed medical practitioner to perform such procedures as may be medically necessary to alleviate the problem. I have had the opportunity to ask questions regarding this release and all of my questions have been answered to my satisfaction. Having understood the above agreement, I freely sign this Permission to Provide Medical Treatment Agreement. I acknowledge that the participant is under the age of 19. I have reviewed the information provided and certify it to be true and correct. I consent to __________________ participating in the evaluation and program. ______________________ Date
_____________________________________________ Signature of Parent or Guardian
DSU Sports Acceleration Training Policy Form
Training Fees 1. 2. 3.
A $150 deposit is required with registration before scheduling any pretests evaluations. The remaining balance of training fees must be paid in full at the first training session, and becomes to our refund policy at that time. Acceleration Programs are non-transferable and are designed to be completed in 6-8 weeks in order to achieve optimal results. The FEE BALANCE WILL BE HELD FOR 60 DAYS FROM THE START OF THE FIRST TRAINING WORKOUT. If training has not been completed August 1, 2009, the remainder of your account will be forfeited.
Refunds 1. 2.
Training fees paid prior to any pre-test and evaluation will are fully refunded. No refunds will be given once an athlete starts an Acceleration Training Program. If an athlete is unable to complete the training, due to an injury that occurred outside of Athletic Republic速 Sports Training or other relevant circumstances that will not permit the athlete to finish, the prorated balance of their training fee may be refunded minus a cancellation fee of $75.00. If at any time an individual is unable to complete a performance training program due to an injury sustained during actual training in any Acceleration program component, the prorated balance of their training fee may be refunded or maintained on account until the individual is able to complete their training. SCHEDULED APPOINTMENTS
Any individual failing to show for a scheduled Acceleration appointment will forfeit a paid session. Cancellations are to be made one day in advance. Athletes canceling on the day of their appointment will be charged for that session. Any athlete that is 5 to 15 minutes late for a scheduled appointment will receive a modified training session to fit the remaining time of the session. If the individual is over 15 minutes late for an appointment, they will forfeit that session. Cash refunds will not be given for a missed appointment.
I understand the Athletic Republic速 Sports Training Policy Form and its conditions. _________________________________ Signature Date _________________________________ Print Name _________________________________ Address
______________________________ Signature Date ______________________________ Print Name ______________________________ Address
REGISTRATION CHECK LIST _____
Athlete Information Sheet Be sure to select a Program option Be sure to sign at the bottom of the page.
Informed Consent and Medical Treatment Agreement Be sure to sign both
Policy Form Be sure to carefully read policies related to refunds and scheduling.
Photocopy of most recent HS Physical Form Could be Form A or B.
DSU SPORTS ACCELERATION PROGRAM 2009 FEE SCHEDULE Advanced Acceleration 24 Workout Package $440 $400 if PAID IN FULL BY JUNE 1 Includes: 1. Any combination of 24 treadmill, plyometric or SportCord sessions, tailored to each athlete’s goals 2. 24 Weight Training Sessions 3. Pre- and Post- training testing for speed, power, flexibility, foot quickness, strength, and gait. Basic Acceleration 18 Workout Package $330 $300 if PAID IN FULL BY JUNE 1 Includes: 1. Any combination of 18 treadmill, plyometric or SportCord sessions, tailored to each athlete’s goals 2. 18 Weight Training Sessions 3. Pre- and Post- training testing for speed, power, flexibility, foot quickness, strength, and gait. 4. RECOMMENDED FOR BEGINNERS. Basic Acceleration 12 Workout Package $250 $225 if PAID IN FULL BY JUNE 1 Includes: 1. Any combination of 12 treadmill, plyometric or SportCord sessions, tailored to each athlete’s goals 2. 12 Weight Training sessions 3. Pre- and Post- training testing for relevant speed, power, flexibility, foot quickness, strength, and gait. Distance Training Program Varies by plan 1. Any of the above Acceleration plans can be tailored for a distance runner. Combination of speed and interval work. Supervised Strength Programs $175 Includes 1. Strength and flexibility evaluations and training prescriptions 2. 18 total body strength workouts (3x per week) supervised by DSU staff, 3. Instruction in proper lifting technique, including free weight exercises 4. This program does not include any Acceleration Training protocols 5. Can be added to a current Acceleration package for an additional $30. Individual Gait or Strength Evaluation