Skills Football Camp

The LEAD Sports Academy
Clinic & Camp Payments to:
Credit card payments
Checks
Are accepted online by paypal at:
Should be made out to LEAD Sports Academy, and mailed to:
LEAD Sports Academy
payment@leadsportsacademy.com
Please include the athletes name and the program they
play for along with
your payment.
PMB #172
52 Mission Circle #124
Santa Rosa, CA 95409
Please include the athletes name and the program they play for along with your payment .
Credit card payments will also be accepted on the day of
the event pending availability.
Cash payments will also be accepted on the day of the event pending availability.
PLEASE DO NOT SEND CASH IN THE MAIL.
If you have questions, need information pertaining to the camp, or would like more information about
The LEAD Sports Academy you can contact us @ www.leadsportsacademy.com
James Solley
Lenny Wagner
Dean of Sales and Marketing
Dean of Education
james@leadsportsacademy.com
lenny@leadsportsacademy.com
LEAD Sports Academy, PMB #172, 52 Mission Circle #124, Santa Rosa, CA 95409
LEAD Sports Academy Coaching Staff
(707) 529-7922
(707) 888-3759
FAX (707) 540-6001
Lenny Wagner
LB Sonoma State
1989-1990
SSU Hall of Fame LB
The LEAD Sports Academy Coaching Staff is made up of
successful current and former college football coaches, as
well as current and former college and professional football players. In addition to the coaches that are listed, also
joining the staff this year are:
Sonoma State
Defensive Coordinator
SSU Hall of Fame Coach
Rob Gatrell
Windsor HS Head Coach
Retired NFL/AFL OL
SRJC
Assistant Head Coach
Defensive Coordinator
2000-2010
Jeff Tubbs
Retired SRJC LB’s Coach
LEAD Sports Academy 2011
LEAD Sports Academy
2011- present
Kevin Balatorre
SRJC QB’s Coach
LEAD Sports Academy 2011
Martin Tevaseu
DL
New York Jets
2010 - present
James Solley
SS Sonoma State
1989-1990
Sonoma State
DB Coach
LEAD Sports Academy
2011- present
Willie Lee
SSU DL Coach
SSU HOF Coach
LEAD
Sports Academy
2011- present
Chauncey Ako
Logo Tevaseu
LB Boise State
2001-2002
LB Texas Christian
2003-2004
SRJC
Defensive Coord.
2011- present
SRJC
Linebackers Coach
2011- present
Ulla Pomele
LB Kansas State
2007-2008
LEAD
Sports Academy
2011- present
Online Payment
Check Box
Mail in Payment
Speed & Agility Camp
#
X
$30.00
=
Total
$100.00 =
Total
Combo Package
Speed & Agility Camp & Football Camp
Football Camp
#
X
Day of Payment
#
X
$110.00 =
Total
Parents or Guardian’s Authorization for Participation
Campers Name:
Date of Birth:
Address:
City:
Current Football Program:
Age:
State:
age:
Name of Parent/Guardian:
Name of Parent/Guardian:
Daytime Phone Number:
Daytime Phone Number:
Evening Phone Number:
Evening Phone Number:
Email Address:
Email Address:
Zip:
year in school:
Other Authorized Person to Contact in Emergency:
Name:
Phone:
Medical History
Medical Difficulty (Asthma, Diabetes, etc):
Eye Glasses / Contacts: Yes No
Medications:
Health Insurance Company:
Physician:
Allergies:
Dose:
Date of Last Refill:
Policy Number:
Phone:
Dentist:
Phone:
I represent that any medication to which Minor is allergic or medications that Minor is currently taking are listed above. I agree that Minor shall bring
medication which Minor is currently taking with him/her to the Camp and that he/she shall consume the prescribed dosage for such medications.
Conduct and Waiver
Please note that any player or coach who behaves in a disruptive manner and/or in a manner which limits other participant’s enjoyment and
learning experience will be subject to immediate expulsion without refund.
For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I ______________________ as parent or legal guardian of __________________, a minor (hereafter “Minor”), hereby grant the
permission necessary to allow Minor to participate in the above Lead Sports Academy Camp(s). I, in my own behalf and on behalf of the Minor, further agree to release and hold harmless LEAD Sports Academy, its officers, employees, sponsors and if applicable, owners and lessors of premises used to conduct the Camp (hereinafter collectively referred to as “Releases’”) from any and all liability for negligence or any other claim, judgment, loss, liability,
cost and expenses (including, without limitation, attorney’s fees and costs) arising out of or connected with the Camp, including any claim arising, out of or connected with any illness or injury (minimal, serious, catastrophic and/or
death) that the Minor may incur or sustain during the Camp, including and claim for the Camps whether or not the Camp actually occurs. I further expressly agree to indemnify and hold harmless Releases’ and against loss from any
further claims, demands or actions that may subsequently be brought by Minor or by any other persons on the account of damages on any character resulting to Minor in any way from the such foregoing activities. I further agree to
reimburse and to make good Releases’ any loss or costs Releases’ may have to pay as a result of any such action, claim, or demand. In the event of an illness or medical emergency, I authorize the LEAD Sports Academy provide
Camp(s) to provide medical care within the limits of their training, to include authority for medical transportation. I further authorize and give consent to medical treatment facility to treat the above Minor by qualified medical
personnel as required. I also certify that my child has successfully completed a physical examination within the past year and has my approval to participate in the LEAD Sports Academy Camp(s) and I give my child permission to
participate in all camp activities. I further acknowledge and understand that I will be responsible for any and all medical and related bills that may be incurred on behalf of the Minor for any illness or injury that the Minor may
sustain during the Camp and while traveling to and from the site for the Camp whether or not the Camp actually occurs.
Appearance Agreement, I understand that LEAD Sports Academy from time to time produces promotional material relating to its programs. I understand that as a participant in and/or a spectator at the Camp, the Minor may be
included in videotapes or photographs taken during the Camp. Thereafter, without reservation or limitations, I, in my own behalf and behalf of the Minor, hereby assign, transfer and grant LEAD Sports Academy, its successors,
assignees, licensees, sponsors, any television networks, and all other commercial exhibitors the exclusive right to photograph and/or videotape the Minor and to utilize such videotapes and photographs and Minor’s name, face,
likeness, voice and appearance as part of the Camp, in advertising and promoting the Camp or in advertising and promoting similar future events. I further understand that neither LEAD Sports Academy nor any third party is under
any obligation to exercise any of the foregoing rights, licenses and privileges.
I, in my own behalf and behalf of the Minor, hereby warrant that I have read this Participant Release and Waiver From and fully understand its contents. I, in my own behalf and on behalf of the Minor, am aware that this Participant
Release and Waiver Form releases Releases’ from liability and contains an acknowledgement of my voluntary and knowing assumption of the risk of injury or illness and/or death. I, in my own behalf and on behalf of the Minor,
further acknowledge that nothing in this Participant Release and Waiver Form constitutes a guarantee that the Camp will occur. I, in my own behalf and on behalf of the Minor, have signed this document voluntarily and on my own
free will.
Signature of Parent or Guardian:
Date:
LEADERSHIP
EDUCATION
ATHLETICS
DISCIPLINE
Skills Football Camp
Friday-Sunday, June 29th, 30th & July 1st
St Vincent’s HS
What to Bring for Football Camp:
HIGH SCHOOL
Speed & Agility Camp
Sunday June 17th,
St Vincent’s HS
What to bring:
Camp Registration Form
Positive Attitude
Athletic Shoes
Water
Camp Registration Form
Positive Attitude
Full Gear - HS ONLY
Mouthpiece — Molded
Cleats
Water
Lunch/Snack
YOUTH
Camp Registration Form
Positive Attitude
No Gear
Cleats
Water
Lunch/Snack