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Camp Shutout Medical Form and Waiverjohnclark2019-09-03T09:26:04-04:00

Athlete / Parent Medical Form

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Athlete Name*
Date of Birth
Emergency Contact*

Medical Information

Does the camper have or have they ever had any of the following:
Heart Murmur
Irregular Pulse
Dizziness/Fainting
Nose Bleeds
Diabetes
Epilepsy
Headaches
Asthma
Inhalers
Heat Exhaustion
Heat Stroke
Heat Cramps
Fractures/Broken Bones
Muscle Injuries
Chicken Pox
Allergies

Rx Information

Is camper taking any medications?
Medication, dosage, indications, physician’s name
Has camper ever sustained a head or spinal injury?
If yes, please explain injury and cause of injury
Has camper ever lost consciousness?
If yes, please explain details
Do you have any other medical problems that could interfere with full participation in physical activities? If yes, please explain
If yes, please explain details
Parent or Guardian Signature*
This is to certify that the athlete named above has been examined by a physician within the past year, and was found to be physically able to participate in vigorous physical activity and competitive athletic sports
Parent or Guardian Name*

Insurance Information

MM slash DD slash YYYY
Parent or Guardian Signature*
BY CHECKING THE BOX ABOVE, I hereby authorize the directors and medical staff of Camp Shutout and Clark Keeper Training to act for me according to their best judgment in any emergency requiring medical attention. I understand that first aid procedures will be rendered by the training staff, and campers will be transported to a hospital if necessary. I hereby waive and release Camp Shutout, Clark Keeper Training and staff for liabilities relation to injury, illness, or expenses incurred. I know of no mental or physical problems which might affect my child’s ability to safely participate in this camp. I will be responsible for any medical or any other charges in connection with their attendance at camp.
Parent or Guardian Signature*
Date Signed

Testimonial

In their own words

Clark Keeper Training is an incredible training program. John is definitely one of the best keeper trainers that I’ve ever had and without him and his work, I would not be the keeper I am today. He will work with your schedule and do everything in his power to make you a better keeper. His training sessions are not only challenging, but you learn something new every time. He adds humor into his sessions in order to better connect with the players, and in order to make training a bit more fun in the midst of a tough workout. John has vast knowledge that he passes on to each player in order for them to improve their game as best as possible. He enjoys every aspect of them game as well as making keepers better all around players and people. I could not tell you how grateful I am for everything that John has done to make me the keeper I am as well as being there for me as a coach. I would recommend Clark Keeper Training to anyone and everyone who wants to become as good of a keeper as they come. Also, check out the Camp Shutout West Michigan Road Show that he puts on every year. Class act all around

I want to share with you a great moment in Gracie’s goalkeeper career.  Yesterday we played in the championship game at the Crusader Cup.  Gracie was only scored on 3 times the entire tournament—her goal was for a shutout but as you know things happen sometimes.  This was our team’s first championship match in our four or five years together.  The game ended up going into overtime and then to a shootout.  I went down and talked to Gracie prior to the start of the shootout.  Her friend and fellow Camp Shutout goalkeeper Auston Ruth was on the sideline for the game to watch and I could tell he was itching to come over to talk to Gracie.  I waved for him to come over and he sprinted over to pump her up for this moment in her career.  It was so cool to stand back and watch the two of them talk goalie talk.  After leaving her, I stood back and watched her do her thing.  When it was her turn on the line, she took her time and did her jumps and stretches just like she learned at Camp Shutout.  She was calm and cool and determined.  Each shooter from the opposing team missed the goal and we ended up winning 2-0 in the shootout.  As one of her coaches, it was awesome to see her so composed and confident in the situation and I have no doubt the shooters were intimated by her.  As her mom, the biggest highlight was to watch her slap gloves with the opposing keeper in between turns

Just wanted to share some exciting (and a proud keeper Mom moment) as Ava’s U11 team participating the Grand Valley soccer tournament this weekend, their team won 1st place!! While Ava did not have a ton of “saving” opportunities, the ones she made were key! The championship ended in a 0-0 tie, so it went to a PK shoot out! So proud of how calm and together she seemed, between every shot she clapped hands with the opponent keep, which was such great sportsmanship! But what really set the tone was Ava made a great diving save to stop the very first PK! She went on to stop 3 total! Her team had a few missed shots, but they ended up winning the shoot out 5-4! What an experience for Ava, one I am sure she will never forget! Ava wanted to make sure I emailed you to let you know her keeper training was in full swing last weekend!

My daughter has trained with John for more than 1 year, less than 2 years. John is a very positive instructor, he dwells on the positive, corrects the negative and moves forward with the patience that most parents do not have – especially me. CKT has made a big improvement in my daughters performance & abilities as many of her teammates parents have given me their unsolicited feedback about the improvement that my daughter displays on the field. CKT is certainly not in it for the money, rather CKT is in it for the love of the position and the associated training.

Aly gained so much from this – not just from the technical side but also an internal growth for her. She walked off the field extremely intimidated – and honestly – she liked that challenge. She was up against bigger, faster and more athletic kids – kids that were “insane” on the field – and it scared her. This is the experience any athlete needs to go through to get to the next step. The coaching staff was great and the fact that you all were able to teach at such a high level yet keep “fun” instilled into this is what makes kids want to play sports. It was said the first day – this will be an extremely intense camp but the key is to still have fun.  Thanks to you and Stan and all the staff .  I would strongly encourage anyone who plays the keeper position to sign up for the “road show” anytime it is available.

On our drive to camp on Sunday, she was very nervous/excited and did not know what to expect, as this was her first year.  She expressed to me reservations about not knowing anyone, and not knowing how she would measure up against the other keepers.  However, on Sunday night when she called me, she did not stop talking about all the great people she was meeting and the skills she would be learning over those next few days.  Those calls did not stop the entire time she was at camp.  By the time I picked her up on Wednesday, she did not want to come home!  She had a wonderful time and felt she learned so much while she was there.  She did not stop telling me about everything she did (some things she was telling me for the second time) and what a GREAT learning experience it was for her.  She said she loved that the staff really interacted with them, even back in the dorms.  She really enjoyed her roommates, and by the end loved getting to know all the keepers at camp.
I cannot thank you enough from myself, and Monica, for this wonderful experience – all of it:  in residence; the staff, the food, the sponsors.  You have surrounded yourself with wonderful people and that shows in this camp.  Thank you! Thank you!

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