SALEM INTERNATIONAL UNIVERSITY – Softball

Pitching Clinic Registration Form

Name_____________________________________________ Grade _________________________

Mailing Address _______________________________________________________________________

____________________________________________________________________________________

School_____________________________________________ Email _________________________

Parent/Guardian ____________________________________ Contact # ______________________

Allergies _____________________________________________________________________________

Medication Instructions if needed

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Other Concerns ________________________________________________________________________

_____________________________________________________________________________________

Other Emergency Contact Name and Number

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I __________________________ give, ________________________________ permission to participate

in the Salem Pitching Clinic. I understand that an injury may occur and will not hold Salem University

Responsible. In the event of an injury I give the clinic permission to care for my child within necessary

means.

Parent/Guardian Signature _______________________________________________________________

Date _________________________

Return to:

Coach Steve Potts

Salem International University

223 West Main Street

Salem, WV 26426