Complete Player Hockey Development VENUE: Shattuck St. Mary s Faribault, Minnesota Complete Player Hockey Development is a Boarding Camp hosted on the campus of Shattuck St. Mary s. We expect players ready to be pushed hard and to take their game to the next level. The on ice and off ice sessions are designed to be demanding and to get players outside of their comfort zone. Skill Development Camp July 1 st -7 th Price: $900 Birth Years 2001-2007 This camp is focused on skill development. We will play 2 games throughout the week, one on Wednesday and one on Saturday. The primary focus of camp is individual skill development on and off the ice. Players will be pushed to their fullest potential and learning how to reach their limits. Pre-Season Training Camp August 5 th -11 th Price: $900 (ONLY 40 PLAYERS ACCEPTED) Birth years 2001-2005 Only 40 players will be accepted to camp. The teams will play three games throughout the week (Tuesday, Thursday and Saturday). This camp is designed to push players and to sharpen skills giving them at the opportunity to start the season at the top of their game. Players will be placed on teams based on their age and skill level. Check in is on Sunday between 2:00-5:00, check out is at 11:00 on Saturday -Players needing airport pick up will need to arrive at MSP airport between 10AM and 2PM on Sunday, and depart on Saturday after 3PM. -We offer room and board between CPHD and SSM camps There is a $300 (non-refundable) deposit required to reserve a spot. To Register: visit www.completeplayerhockey.net or call 952-220-8424
Player information Last Name: First Name: Birthday: Age: Address City State Zip Parent Names: Country Parent Email: Home Phone: Parent Cell: Player Cell: Player Email: Roommate Request: Hockey Information: Circle Week(s) attending: Skill Development Camp Pre-Season Training Camp July 1-7 $900 August 5-11 $900 Level: Position: Height: Weight: --Please make checks payable to Complete Player Hockey Development-- Please mail $300 non refundable deposit (per camp), or full payment to: Jason Horstman 1120 Shumway Ct Faribault MN, 55021 Cell- 952. 220. 8424. Please charge the amount below: Or provide a credit card number $ CC#- - - - EXP: / CVC: Signature:
TRANSPORTATION FORM The following are the transportation plans for (Player Name) We will bring our son on the day of registration (Does NOT need airport transportation.) We will pick up our son on the last day of camp. (Does NOT need airport transportation.) OR Our son will travel via airplane and needs transportation to and from SSM Our son will be flying as an unaccompanied minor. (I have made arrangements with the airlines and paid the unaccompanied minor fee) ARRIVAL TO SSM Airline: Airport/ City departing from: Day of week and date: Flight Number: Flight arrival time: A.M or P.M. Minor: (Yes or No) DEPARTURE FROM SSM Airline: Airport/ City traveling to: Day of week and date: Flight Number: Flight departure time: A.M or P.M. Minor: (Yes or No)
Complete Player Hockey Development In consideration of being allowed to participate as a student, instructor, counselor, assistant, or volunteer (herein called participant ) in a Complete Player Hockey Development camp or Clinic ( CPHD ), the undersigned acknowledges and agrees that: 1. The sports of ice-skating, ice hockey, in-line skating and dry land sporting activities have inherent physical risk that may result in serious damage, personal injury, paralysis, or death. Using proper equipment, following the rules and exercising discipline will reduce the risks. 2. I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for my child s participation. I willingly agree that my child and/or I will comply with the stated and customary terms and conditions for participation. I however recognize that doing so will not eliminate all risk from the activities. If, however, I observe any unusual significant hazard during my presence I will remove myself or my child from participation and will immediately bring such hazard to the attention of the nearest official. 3. Participant will not hold CPHD or any of its employees, officials, owners, managers, proprietors, designees, or the ice rink or employees of the ice rink used by CPHD, liable for injury that the student may sustain, at, or relating to any CPHD activity. 4. Participant is responsible for any and all medical costs for any injuries arising from or around CPHD activities. 5. Participant has no known medical condition that restricts or prohibits participation in ice hockey, ice skating, inline skating or any related activity. Nor does the participant have any known medical condition, which puts him or her at greater risk of injury or death resulting from any risks associated with participating in the clinic or camp, whether such risks are known or unknown to parent or participant. CPHD recommends a medical examination before participation. 6. Participant shall act in a mature and responsible manner. Any behavior that CPHD deems to endanger the safety of persons or property, or jeopardize the CPHD ability to reasons: a) financial delinquency; b) failure to abide by all CPHD and ice rink rules and directives; c) falsification of registration information. 7. CPHD may use, without compensation to the undersigned participant, any photo, audio and/or video recording of any CPHD activity in which the participant appears, for promotional, advertising or educational purposes. 8. I understand that neither CPHD nor the ice facility are responsible for any loss or damage to personal items at the rink. 9. The undersigned acknowledges that CPHD owners, managers, agents and representatives have made no representation, warranties, inducements or promises which are not contained herein and that this signed form represents the entire agreement between the undersigned and CPHD. 10. In the case of a medical emergency I give permission for CPHD, its officers, employees, instructors, and agents to seek medical attention for myself (if over 18) or my child, if I, the parent or legal guardian, am absent. I have read this agreement, fully understand its terms, and sign below voluntarily and without inducement. X (Signature of Parent or Guardian-Self if over 18) Date X (Print Parent/Guardian Name-Self if over 18)
Dear Parents, We are looking forward to having your son or daughter on campus this summer. In the event that he or she needs medical attention, we want to be able to be prepared. Therefore, we are asking that you please take the time to read the below information and to fill out the appropriate health forms as indicated and return them as soon as possible. Paperwork Requirements As required by law, the school s medical forms must be completed before a camper arrives on campus. Any camper with a) a chronic condition (i.e. asthma) requiring prescription medication or b) a recent serious illness or injury must have a physical exam. If any required section is not completed, or if immunizations are not up to date, the school reserves the right to refuse a camper s participation in any activity on campus, including dorm residing. 1. All campers must have the following forms completed: a. Waiver and Release of Claims b. SSM Summer Programs Health Form c. Medical Information and Consent Form d. Non-Prescription Medications 2. All campers must provide a copy of their health insurance card (front and back). This is necessary in case of emergencies. 3. Campers who have had any bouts or exacerbations within the last 6 months of the following illnesses: asthma, diabetes, Mononucleosis, 2 head injuries, or any orthopedic injury (sustained within the last month) must have a Doctor complete a physical exam. Please contact Emily Canney at Emily.Canney@s-sm.org if in need of a form for a physical. All paperwork can be returned to Jason Horstman 1120 Shumway Ct. Faribault MN. 55021 Telephone 952-220-8424 completeplayerhockey@gmail.com Medical Care The Kramer House Health Center is located on campus and is equipped to handle routine health care needs. A camp nurse will hold office hours at the health center every day from 7AM to 10AM unless otherwise noted. During off hours, a nurse will be on call. There is also an athletic trainer available. In the event that urgent medical care is needed, a hospital with a full-service emergency room is within five minutes by car. Please indicate on health forms if prior authorization for care is needed for insurance. In the event of injury or illness, Shattuck St. Mary s reserves the right to require the camper to return home. If more than one overnight monitoring by a nurse is deemed medically necessary, a fee of $200.00 per night will be charged to the family. Our medication policy consists of the nurse collecting all controlled prescription medications at check-in. Medications will be dispensed in the mornings in the cafeteria by a nurse and in the evenings in the dorms by a nurse. It is the camper s responsibility to see the nurse for their medications. Some over-the-counter medications are available from the nurse, dorm parent, or trainer upon request. Please complete the Non-Prescription Medications form to indicate what your child is allowed to have. Please avoid bringing over-the-counter medications (unless the medication is not in our inventory) as we have these available for your child. Students who wear glasses should bring an extra pair if possible. One pair should be shatter-proof for athletic purposes. Students who wear contact lenses should also bring a pair of glasses. Emily Canney Summer Nurse Coordinator Emily.Canney@s-sm.org 507-333-1644 (office) 507-333-1600 (fax)
1. Waiver and Release of Claims 2017-2018 Please read the form below carefully and be aware that in registering yourself or your minor child for participation in a camp at Shattuck-St. Mary s, you will be waiving and releasing all claims for injuries you or your child/ward might sustain arising out of this and all future activities at Shattuck-St.Mary s School. I recognize and acknowledge that there are certain risks of serious injury to participants in this activity and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I or my child/ward may sustain arising out of this and all future activities. I agree to waive and relinquish all claims I or my child/ward may have arising out of this and all future activities against Shattuck St. Mary s, and its officers, directors, shareholders, agents, servants, and employees. I do hereby fully release and discharge Shattuck St. Mary s, and its officers, directors, shareholders, agents, servants, and employees from any and all claims from injuries, damages or loss which I or my child/ward may have or which may accrue to me or my child/ward arising out of this and all future activities. I further agree to indemnify and hold harmless and defend Shattuck St. Mary s, and its officers, directors, shareholders, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me or my child/ward, and arising out of, connected with, or in any way associated with this and all future activities. In the event of an emergency, I authorize Shattuck St. Mary s officials to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary my child's immediate care and agree that I will be responsible for full payment of any and all medical services rendered. I have read and fully understand the above waiver and release of all claims. Furthermore, I give permission for my child s picture(s) and name to be published in school publications, videos, websites, brochures, etc. I give permission for my child to be quoted in school publications. I give permission for my child s name to be published on the school s websites. I give the school permission to issue press releases to media sources concerning my child. I hereby grant permission to use any and all photographic imagery and video footage taken of my child, without payment or any other consideration. I understand that such materials may be published electronically or in print, or used in presentations or exhibitions. Student Signature (if over 18) Date / / Parent Signature (if student is under 18) Date / / Student Name (please print)
2. SSM Summer Programs Health Form Boys Hockey Girls Hockey Figure Skating Synchro ESL Other (name) Student Name M/F Birthdate / / Grade History Circle Yes (Y) or No (N) Have you or do you have: 1. Injury or illness since your last exam? Y / N 24. Have you had? (circle all that apply) 2. A chronic or ongoing illness? Y / N anemia sprain 3. Ever been hospitalized? Y / N reason abnormal bleeding diabetes 4. Ever had surgery? Y / N abnormal bruising diabetes 5. Allergies to medications, bee stings, pollens, broken bones vision loss or foods? Y / N stress fractures scoliosis Please list seizures heart murmur Type of reaction: viral myocarditis depression 6. A heart murmur? Y / N chicken pox rheumatic fever 7. High blood pressure? Y / N hearing loss eating disorder 8. Restricted from sports for heart problems? Y / N single organ chemical dependence 9. Ever had a concussion? When Y / N mononucleosis high blood pressure 10. Ever had a head injury? When Y / N hepatitis sickle cell disease 11. Knocked out or had memory loss? When Y / N eye loss undescended testicle 12. Asthma? List medication Y / N ADD/ADHD other psychological 13. Severe viral infection last month? Y / N Explain Female Athletes: Do you have regular menstrual periods? Y / N 25. Do you use any special equipment? Y/N When was your most recent menstrual period? 26. Do you have any other concerns? How many periods did you have in the last year? During or after exercise have or do you ever: 14. Fainted or felt dizzy? Y / N 15. Had chest pain? Y / N 16. Had racing heart or skipped heartbeats? Y / N 17. Do you tire more easily than your friends? Y / N 18. Become ill from exercising in the heat? Y / N 19. Wheeze, cough, or have trouble breathing? Y / N 20. Has any family member or relative died of a heart problem before age 35? Y / N Before age 50? Y / N 21. Height 22. Weight 23. List medications currently taken daily: I do not know of any existing physical or additional health reason that would preclude participation in sports. I certify that the answers to the above questions are true and accurate. I approve participation in athletic activities. I hereby authorize release to the school s athletic trainer, nurse, coach, and medical providers of the information contained in this document. Upon written request, I may receive a copy of this document for my personal health care provider. Athletes must have written permission from the treating physician to participate if wearing a cast Parent or legal guardian signature: Date: / /
3. Medical Information and Consent Form We/I, the parents/legal guardians of, / /, M/F, Boarding/Day, (Student name) (Date of birth) (Circle one) authorize the SSM Health Center staff, including, without limitation, the school medical director, nurses or athletic trainers, to administer to our child, any health care deemed advisable by a medical doctor, registered nurse, dentist licensed by the State of Minnesota or any other qualified health care professional under the general supervision of a physician as long as he/she is a camper at Shattuck-St. Mary s School. In the event of an emergency, we consent to the immediate transfer of our child to any hospital or appropriate health care facility. We authorize a representative of the Health Center to consent on our behalf to any emergency medical or dental treatment to be rendered to our child and to release pertinent information to the appropriate health care professionals. All reasonable attempts to contact us in advance of such emergency or other non-routine treatment will be made, provided medical circumstances permit. We also authorize the release of information by any off-campus provider to the Shattuck-St Mary s Health Center. We authorize the health care professionals at the Health Center to disseminate any pertinent medical information to the appropriate school personnel: trainers, coaches, teachers, dorm parent and/or any other school personnel deemed necessary. This consent may be used for any off-campus health emergencies. In such cases, the SSM representative present shall be deemed a representative of the Health Center for the purpose of authorization and consent. We agree that we are exclusively responsible for the payment of all medical and dental services rendered to our child other than routine services provided directly by the School s Health Center. Any copy of this consent shall have the same force as the original. Parent/Guardian (print) (signature) Date Street Address Town/City State Zip Code Country Home Phone Cell Phone (student) Work Phones (mother) (father) Cell Phones (mother) (father) E-mail addresses (mother) (father) *Emergency Contact (primary) name relationship home/cell Secondary name relationship home/cell *ALLERGIES *CURRENT MEDICATIONS *SIGNIFICANT MEDICAL HISTORY LAST TETANUS / / DOES YOUR STUDENT S HEALTH INSURANCE REQUIRE PRE-AUTHORIZATION? Yes ( ) No ( ) *While it is the School s ethical responsibility to respect and maintain patient confidentiality, we must be able to share pertinent information on a need to know basis to promote the health and safety of an individual student with appropriate school personnel as outlined in the School Handbook.
4. Non-Prescription Medications The following is a list of non-prescription/over-the-counter medications that Shattuck-St. Mary s Health Center nurses are able to administer to the students as needed/directed per standing orders from our Medical Director. Acetaminophen (Tylenol) Debrox drops Mylanta Allegra Delsym cough syrup Pepto Bismol Bacitracin/Neosporin Glyoxide drops (canker sores) Robutussin Benadryl Hydrocortisone 1% crean Robitussin DM Biofreeze (topical analgesic) Hypotears Sudafed Blistex Ibuprofen (Advil) Sunscreen SPF15 Calamine Lotion Immodium Tinactin (antifungal) Carmex Kaopectate Tolnaftate(antifungal) Cepacol Lozenges Metamucil Tums Chloraseptic Spray Midol Zantac Claritin Milk of Magnesia Zyrtec PARENT/GUARDIAN AUTHORIZATION 1. I give permission for the school nurses, athletic trainers, and/or school personnel designated by the school nurses to administer medications listed above to my student,, when he/she is on campus or on an off campus trip EXCEPT for the following: 2. I release all school personnel from any and all liability in the event of any adverse reaction resulting from the use or administration of the medication(s) in relation to this request when the medications are given as ordered. 3. I will notify the Health Center of any changes to the list of non-prescription medications excepted or allowed. 4. I give permission for the nurse to communicate with the appropriate school personnel and consulting physician regarding any information that needs to be disseminated or obtained concerning nonprescription medication. Parent/Guardian Signature Date / /
What To Bring: - Cell phone to make calls home - Light Jacket or sweatshirt, cap or hat, pair of sweatpants - Full hockey gear and sticks - Swim suit and towel (optional) - Good pair of running shoes for off-ice training - Sleeping bag OR sheets and blanket, pillow - Soap towels, wash cloths, toothbrush, toothpaste, toiletries - Fan (highly recommended) - Extra spending money (on averabge $100 is deposited to the camp bank) - Roller baldes, inline skates, street hockey stick (optional) - Alarm clock - Wrist watch - Bedside flashlight (optional) 1120 Shumway Ct. Faribault MN 55021