Bruin Baseball Hitting Academy

BRUIN BASEBALL HITTING CLUB APPLICATION: Makes Checks Payable to: Western Branch High School

COST OF CLUB MEMBERSHIP: $100.00 per camper SITE OF HITTING CLUB: Western Branch Baseball Indoor hitting facility CLUB INSTRUCTORS: Western Branch High School Baseball Staff PLEASE CIRCLE SESSION ATTENDING: o All hitting sessions limited to 10 players per session  Session #1 Mondays 11/10/14 – 11/24/14 6:00 pm – 7:00 pm (Grades K – 7)  Session #2 Wednesdays 11/12/14 – 11/26/14 6:00 pm – 7:00 pm (Grades K – 7)  Session #3 Saturdays 11/15/14 – 11/29/14 10:00 am – 11:00 am (Grades K – 7)

NAME OF CAMPER: ______

AGE OF CAMPER: ______

PARENT/GUARDIAN: ______

ADDRESS: ______

PHONE NUMBER (HOME): ______

CELL NUMBER: ______

EMERGENCY CONTACT (NAME): ______

(PHONE NUMBER): ______

MEDICATION ALLERGIC TO: ______

MEDICATION BEING TAKEN NOW: ______

RELEASE/MEDICAL INFORMATION: All club members must have insurance in the event that the club member has an injury or illness while attending the hitting club. Each member will be responsible for their own medical expenses if such an emergency occurs. By signing this medical release form, no staff member or player of Western Branch High can be hold liable for any injury that may occur during the Bruin Hitting Club. Please complete the following information below: Insurance Carrier: ______Policy #: ______Relationship to camper: ______I hereby give my permission for Emergency medial treatment in the event that I cannot be reached. This also assures the academy that my child is in good physical condition and health and may participate in all academies.

Signature:______Date:______WESTERN BRANCH BASEBALL BOOSTER CLUB 4025 Hawksley Dr Chesapeake, Va 23321