CAMP / CLINIC AUTHORIZATION FORM

Sport: _____________________Coach/Camp Director: ____________________

Name of Camp:____________________________________________________
Address:           ____________________________________________________
Phone:              ______________________     FAX________________________
Email:               ________________________________
Website:           ______________________________________________

Insurance Provider_________________________________________________
Phone                    _______________________

                                                            Time             Age Group    # Of Participants
Projected Dates:____________       __________   __________        _________
                          ____________       __________   __________        _________
                          ____________       __________   __________        _________
                          ____________       __________   __________        _________
                          ____________       __________   __________        _________
                          ____________       __________   __________        _________
                                   
Facilities to be utilized:______________________________________________
                                    ______________________________________________

Facility prep/set up required:__________________________________________
                                             __________________________________________
                                             __________________________________________
                                           
Equipment to be utilized:      __________________________________________
                                             __________________________________________
                                             __________________________________________

CSUF Certified Athletic Trainer Requested ________ @ $25.00 per hour 
CSUF Student Athletic Trainer Requested  ________ @ $15.00 per hour
                (first responder only)
CSUF Athletic Training Facilities/Equipment Requested_________ @ $25.00 per
   (permitted only if hiring CSUF athletic trainer)                                                                                                        week
Hiring Outside Athletic Trainer _______                                                                                                    

Camp/Clinic Authorization Form (cont.)                                                   Pg. #2

Registration Fee: $_________ 

Will any discounts or scholarships be awarded?  Yes________  No___________

If yes, on what basis:_______________________________________________

Will any awards or prizes be given? __________________

Please describe: __________________________________________________
                           ___________________________________________________

Sponsor (if any)                                           Item                                       Value
_______________________          ________________________        ________
_______________________          ________________________        ________              
_______________________          ________________________        ________
_______________________          ________________________        ________   

Notes:___________________________________________________________
          ___________________________________________________________
          ___________________________________________________________
          ___________________________________________________________
          ___________________________________________________________
          ___________________________________________________________
          ___________________________________________________________
          ___________________________________________________________
           
Attach a copy of all brochures/fliers etc.

Please note, approval is contingent upon the availability of the facilities

Camp Director Signature                 ____________________________________

Head Coach Signature(if different)  ____________________________________

Compliance Approval Signature      ____________________________________

Facilities Approval Signature           ____________________________________                

Sr. Associate AD/SWA Signature   ____________________________________

Cc: Facilities, Resource Manager, Business, Athletics 
      Training, Personnel