Athletics Consent and Release from
Liability
Girls Basketball
2nd – 4th Grade
Skills Clinics
Parents Release: I hereby authorize my child’s
participation in the Viking Youth Basketball
Clinic. I know of no mental or physical problems
which may affect my child’s ability to safely
participate in this camp. I hereby authorize the
camp staff to act for me according to their best
judgment in any emergency requiring medical
attention. I acknowledge that I am responsible for
any and all medical expenses, and will not hold
the Forest Grove School District, Viking Youth
Basketball Clinic or its staff, liable for any
injuries, illnesses, or expenses incurred while my
child is at the Viking Youth Basketball Clinic.
Medical Insurance Company:
________________________________________
Policy Number:
________________________________________
Any Medical Concerns:
________________________________________
I/WE HAVE READ THIS CAREFULLYAND
KNOW IT CONTAINSARELEASE.
Additional Information
The purpose of these clinics is not only to begin
teaching these young girls the skills that are
necessary for them to be successful, but also to
develop a love for the game of basketball. The
coaches are looking forward to working with all
of the young girls and helping them to become
better players.
Date: __________________
Name of Parent/Guardian
__________________________________________________
Signature of Parent/Guardian
__________________________________________________
A typical day will consist of warm-ups, drills,
individual instruction, and offensive skill
development. Two main areas of focus will be
on developing proper shooting form, and
improving ball handling abilities.
Every Wednesday
November 5th – December 17th
(Except for week of Thanksgiving)
Grades 2-4: 3:45 PM – 5:15 PM
At Joseph Gale Elementary
School
Practice Makes
Permanent!!
Mail Camp Brochure and Fee to:
Viking Girls Basketball Youth Clinic
c/o Dan Lumpkin
Forest Grove High School
1401 Nichols Lane
Forest Grove, OR 97116
Application Form
Address: __________________________________
City/Zip Code: _____________________________
Parents/Guardians: __________________________
Cost:
$30 per player
(Each player will receive a basketball)
Please make checks out to:
Forest Grove Girls Basketball
__________________________________________
Phone: _______________________ Age: _______
Grade level: ______________
Session is every Wednesday (Nov. 5th – Dec. 17th)
Except week of Thanksgiving
Registration:
We would prefer that all campers
register prior to Friday November 1st.
If you can’t register by November 1st, you
may still register on the first day of the
clinics. Registration on the first day of
camp will take place 15 minutes prior to
your daughter’s first session.
Youth Clinic Staff:
Name: ____________________________________
This year, each of the girls will receive a
basketball for participating in the clinic!!
Clinic Director:
Dan Lumpkin – Head Girls Basketball
Coach at Forest Grove High School. This will
be his 6th year as the Head Coach of the Girls
Basketball program in Forest Grove. Coach
Lumpkin has 8 years of coaching experience
at the High School and College levels. He
played his college basketball locally here at
Pacific University.
Clinic Coaches:
Lisa Harings – After playing one year at
Oregon State, coach Harings continued her
athletic career here at Pacific University where
she was a three-sport star. She is one of the
top players to ever come out of the Pacific
women’s basketball program, and she was
recently inducted into the school’s athletic
Hall of Fame. She has continued on to coach
at the high school and youth levels in both
basketball and soccer.
Geoff Vernon – Coach Vernon brings a
wealth of experience as both a player and a
coach. Coach Vernon played his college ball
here at Pacific, where he spent four years as
one of the team’s top offensive players. After
his playing career, Geoff spent 9 seasons as an
assistant coach in the Pacific University men’s
program and has also spent a couple years as a
varsity assistant for the Forest Grove HS boys
program.