hooty
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Joined: 5/9/2007
From: never never land
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The Nutmeg Scramblers will be hosting a two-day Youth Camp!
Who: Open to boys and girls ages 10-16.
When: April 9, 10, 11, 2010
Where: Union, CT - Martin & Tina Michalec’s
Price: $160.00 Checks Payable to “Nutmeg Scramblers”
Information
We are focused on teaching everyone from first time trail riders to the everyday riders, and having fun!!
Come Learn: riding skills, suspension tips, bike maintenance, and nutrition advice from some of NETRA’S top riders.
AA national riders and top enduro and harescramble riders will be on hand.
We will have small groups to keep everyone busy and interested throughout the entire day.
NETRA sanctioned and insured.
There will be EMT’s and chaperones on-site at all times.
All participants must be NETRA members and have health insurance.
There are only 50 spots available that are filled on a first come-first served basis.
A non-refundable $160.00 event fee must accompany a completed application and medical form - received by March 1, 2010!
Upon receipt of your pre-registration forms & payment, a complete information packet will be mailed to you.
Campers should arrive in Union between 3-5 pm on Friday April 9 and be picked up by 12:30 pm on Sunday, April 11.
Camping will be outdoors. Needs: sleeping bag, sleeping mat, tent, toiletries, dirt bike, fuel, helmet, chest protector, elbow pads, knee guards, boots, jerseys, pants, gloves, and goggles.
Mail Entrys to:
Mike Hery
16 Old County Road
Willington, CT 06279
Questions? contact Youth Coordinator Mike Hery at 860-377-0923 or
mhery01@yahoo.com OR Steve Metsack at 860-428-3711 or samgdm328@yahoo.com
Donations: if your business would like to donate…please contact the trail bosses.
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Rider Application
Entry Information
A Nonrefundable $160.00 Event Fee, completed application & medical form are due by March 1, 2010
Check Payable to: “Nutmeg Scramblers”
Mail to: Mike Hery
16 Old County Road
Willington, CT 06279
You will receive a confirmation packet containing: directions,
weekend itinerary, and a packing checklist once payment is received.
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RIder Name: __________________________________________________________________
Address: _____________________________________________________________________
City: ___________________________________ State: __________ Zip: _______________
Home Phone: ___________________ Cell: _______________ Rider Age: _____________
Netra #: ________________________
PARENT/EMERGENCY CONTACT INFO: name: __________________________________
Tel: __________________ OR NAME: _______________________ TEL:_______________
Bike Information:
Make: ________________________ Model: __________________________
4- Stroke or 2-Stroke
Number of Years Riding Experience: ____________________________
How would you best describe your skill level? (circle one)
Beginner, Novice, Amateur, Expert
Have you ever raced in any organized events? NETRA, NEMA, NESC? __________
______________________________________________________________________________________________________
Medical Form
Rider’s Name _______________________________________________________ Age___________________
Home Address______________________________________________________________________________
Phone ______________________________________________________________________________________
Emergency Contact ___________________________Phone(s) ___________________________________
SECONDary EMERGENCY CONTACT:_______________________ Phone______________________________
Doctor’s Name_________________________________________ Phone______________________________
Insurance CARRIER_________________________________________________________________________
Group#________________________________________________Id#__________________________________
Health History
Do you have any allergies? Y N N/A
If yes, Allergic to _________________________________________________________________________
Do you carry an Epi-Pen? Y N N/A
Are you a Diabetic? Y N N/A
Do you take Insulin? Y N N/A
Do you manage your own injections? Y N N/A
Do you use an inhaler? Y N N/A
Have you experienced any attacks during riding? Y N N/A
Are you taking any medications daily? Y N N/A
What are they?____________________________________________________________________________
Do you have any bleeding disorders? Y N N/A
Are you an epileptic? Y N N/A
(if yes, Date of your last seizure activity) ______________________________________________
Date of you last exam___________________ Date of last tetanus shot_____________________ Any other medical conditions? Specify ____________________________________________________
____________________________________________________________________________________________
Medical Release
I hereby grant permission to the Nutmeg Scramblers Motorcycle club to seek medical attention for my child _____________________________ in the event of illness or injury during participation in the netra Youth Camp from April 9-11, 2010. I am fully aware of all risks associated with participation in this event and have been encouraged not to allow participation unless my child is physically capable and properly insured.
PARENT/GUARDIAN SIGNATURE__________________________________________________
PRINT NAME__________________________________________________DATE:______________________
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2010 NETRA Youth & Pee Wee Camps - 
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