Medical Insurance Waiver. Name: Primary Care Physician: Office Phone Number: Is camper currently being treated by a physician for injury or illness?

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1 Coaching Staff Coach Mike Williams is currently in his first season as head coach for the Grand Valley State Lakers. He has over 27 years of coaching experience at the high school, Division III, Division II, and Division I levels, with a record as a head coach, and was named WHAC Coach of the Year ( ) and WBCA Region Coach of the Year. While in his first stint at Grand Valley Coach Williams won a division ii national championship. Associate Coach Phil Sayers enters his fourth season with the Grand Valley State women's basketball program. After spending the first three seasons as an assistant coach, Sayers was promoted to Associate Head Coach shortly after the campaign. Sayers is responsible for guard development, offensive breakdowns and game preparation. He also serves as the team's recruiting coordinator. Assistant Coach Kylie McKay is entering her first year as an assistant coach for the Grand Valley State women's basketball program. She joins the program after finishing her three year career as a student athlete, graduating from WMU. McKay helps coordinate strength & conditioning, and assists in player development for the Lakers. Assistant Coach Marissa Coolman is entering her first year as an assistant coach for the Grand Valley State women's basketball program. She joins the program after a four-year career as a student -athlete at Bethel College in Mishawaka, Indiana. Coolman will assist the program in all areas. Coolman was a two-year captain for the Lady Pilots. Medical Insurance Waiver Name: Primary Care Physician: Office Phone Number: Is camper currently being treated by a physician for injury or illness? If yes, explain: List Medical Conditions: List medications currently taken: List allergies: Policy Holder s Name: Address: City/State/Zip: Primary Phone: Plan #: Group #: Policy # Contact #: Relationship to Camper: Emergency #: As the parent/guardian of the camper listed above I hereby agree to the following as a condition of s participation in the GVSU summer camp program and related services. I give my permission to GVSU, St. Mary s Hospital, Spectrum Health Care System, North Ottawa Community Hospital, Metropolitan Health Care System or other health care providers to provide, seek, obtain, or approve any routine, necessary, or emergency health care during the camper s involvement in the GVSU summer camp program. I understand that this authorization is given in advance of any specific diagnosis, or treatment or medical care being required and is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable. I understand my rights under the Health Insurance Portability and Accountability Act (HIPPA) and authorize GVSU to release information as necessary for managing summer camp health care. I attest that a physician has examined the camper in the past twelve months and he/she was found to be in good health. I attest that currently there is no medical reason for the camper not to participate in the strenuous physical activities of the sports camp program. I acknowledge that participation in sports camp and related activities involves assumed and inherent risk of personal injury. I assume such risk on behalf of the camper and give my permission to the camper to participate in all sports camp activities. I release and agree to hold harmless GVSU, its Board of Trustees, students and employees from all claims, actions, damages, and liabilities for personal injury or damage relating to or arising out of any sports camp activity except where the injury or damage is caused by the gross negligence of the university s employees. I understand that the camper will be subject to the rules and regulations of the GVSU sports camp. I understand that any person who repeatedly disobeys camp policies or procedures will be immediately expelled from camp. GVSU is not responsible for lost or stolen property. Signature of Parent or Guardian Date SUMMER CAMPS Directed by Mike Williams GVSU Women s Basketball Coach Shooting Camp June 20th Ball handling/passing Camp June 21st Scoring/Position Camp June 22nd Varsity 1 Day Elite Camp June 23rd Middle School Overnight Elite Camp July 31st August 2nd Varsity/JV Team Camp July 18th-20th More information and registration:

2 Camp Date Time Ages Cost Shooting Camp June 20th 9:30am-3:30pm 8-17 $60* Ball handling/passing Camp June 21st 9:30am-3:30pm 8-17 $60* Scoring/Position Camp June 22nd 9:30am-3:30pm 8-17 $60* Varsity 1-Day Elite Camp June 23rd 11:00am-7:00pm Varsity Only $75 Middle School Overnight Camp July 31st August 2nd July Aug Grades 6th-9th Below Varsity/JV Team Camp July 18th-20th July July JV & Varsity Below * If attending all three skill day camps (shooting, ball handling & scoring) will receive a $10 discount per day; total cost $150 All camps are conducted at GVSU Fieldhouse Arena on the Allendale Campus Complete Payment is due by the start of camp There will be a full time athletic trainer available throughout the camp day. Shooting Camp (June 20th) A day dedicated to the fundamentals of a perfect shot. We ll break down shot mechanics from footwork, timing, balance, and release. Meals will not be provided so please bring a lunch! Each player will go home with not only new skills, but a camp t-shirt and an outdoor basketball. Ball handling/passing Camp (June 21st) Players will expand their ball control skills as they go through drills to emphasize balance, footwork, and court vision. Meals will not be provided so please bring a lunch! Each player will go home with not only new skills, but a camp t-shirt and an outdoor basketball. Scoring/Position Camp (June 22nd) A camp dedicated to developing players into a defense s nightmare. Learning new moves and reads to help them expand into a scoring threat from all positions on the court. Meals will not be provided so please bring a lunch! Each player will go home with not only new skills, but a camp t-shirt and an outdoor basketball. Varsity 1-Day Elite Camp (June 23rd) A serious no frills camp featuring some of the best talent in the state. Varsity level players will learn individual and team concepts in a highly competitive setting. Middle School Overnight Camp (July 31st-Aug 2nd) A chance for middle school aged athletes to be amerced in skill development, fundamental expansion, and team building exercises. Three days guaranteed to expand their skill set and send them home with new drills to master. Cost: Overnight (w/ meals) $225 Commuter (w/ meals) $160 Commuter (NO meals) $125 Varsity/JV Team Camp (July 18th-20th) A chance for high school teams to test their skills against other area competition. Teams will enter pool play the first day which will determine their seeding for bracket play. Bracket play will be a double elimination winner take all gauntlet. All teams will leave with camp t-shirts. Cost: Overnight (w/ meals) $190 Commuter (w/ meals) $140 Commuter (NO meals) $90 Packing for Overnight Camp Recommended that players bring either a sleeping bag, or a blanket and sheets, as well as a towel. Athletic apparel for each day, extra socks, a swimsuit, and spare contacts, and necessary medications. Spending money for the snack bar and campus store, and a fan for the dorms. GVSU is not responsible for any lost or stolen items. Register online at: Registration Form Name: Age: Grade: Home Address: City: State: ZIP: Graduation Year: School: Phone: Shirt Size (Youth or Adult): Refund Policy A $50 non-refundable deposit will be required with registration. Students leaving the camp will not receive a refund unless they are forced to leave early for medical reasons. Please Make Checks Payable to: GVSU Women s Basketball To Pay By Credit Card: Call Janine Warfield at (616) Mail to: 1 Campus Drive 192 Fieldhouse Allendale, MI Register Online at:

3 Grand Valley State University Camp Medical Information Form 192 Fieldhouse, Allendale, MI Fax: (616) Section 1: Camper Information Home Phone Address Camp Sport Name Camp Dates Date of Birth Office Primary Care Physician Phone Is the camper currently being treated by a physician for an injury or illness? apple Yes apple No If yes, explain: List all medical conditions the staff should be aware of: List all medication the camper is currently taking: List all allergies the camper has: Section 2: Insurance Information Day Address Phone Cell/ Pager Policy Holders Name Evening Phone Date of Birth Social Security # Address Phone Insurance Company Group Number Plan Number Contract Number Policy Number Section 3: Emergency Contact Name Daytime Phone Cell/Pager Evening Phone As the parent/guardian of the camper listed above I hereby agree to the following as a condition of INSERT CAMPER S NAME s participation in the Grand Valley State University (GVSU), summer camp program and related activities. I give my permission to GVSU, St. Mary s Hospital, Spectrum Health Care System, North Ottawa Community Hospital, Metropolitan Health Care System or other health care providers to provide, seek, obtain, or approve any routine, necessary, or emergency health care during the campers involvement in the GVSU summer camp program. I understand that this authorization is given in advance of any specific diagnosis, or treatment or medical care being required and is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable. I understand my rights under the Health Insurance Portability and Accountability Act (HIPPA) and authorize GVSU to release information as necessary for managing summer camp healthcare. I attest that a physician has examined the camper in the past twelve months and he/she was found to be in good health. I attest that currently there is no medical reason for the camper not to participate in the strenuous physical activities of the sports camp program. I acknowledge that participation in sports camp and related activities involves assumed and inherent risk of personal injury. I assume such risk on behalf of the camper and give my permission to the camper to participate in all sports camp activities. I release and agree to hold harmless GVSU, its Board of Trustees, students and employees from all claims, actions, damages and liabilities for personal injury or damage relating to or arising out of any sports camp activity except where the injury or damage is caused by the gross negligence of the university s employees. I understand that the camper will be subject to the rules and regulations of the GVSU sports camp. I understand that any person who repeatedly disobeys camp policies or procedures will be immediately expelled from camp. GVSU is not responsible for lost or stolen property. Signature of Parent or Guardian Date

4 PARENT & ATHLETE CONCUSSION INFORMATION SHEET WHAT IS A CONCUSSION? WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION? DID YOU KNOW? SYMPTOMS REPORTED BY ATHLETE: SIGNS OBSERVED BY COACHING STAFF: Rick Snyder, Governor James K. Haveman, Director IT S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON

5 CONCUSSION DANGER SIGNS WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION? WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS? TO LEARN MORE GO TO >>