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CLINIC REGISTRATION FORM Please fill out all information requested so we can maximize your experience. NAME:_____________________________________________ CLINIC DATE:____________ ADDRESS: _________________________CITY: ____________ STATE:____ ZIP:________ PHONE:______________________ E-MAIL:_______________________________________ EMERGENCY CONTACT: ______________________________ RELATION:_____________ EMERGENCY CELLPHONE:____________INSURANCE:____________________________ DOB:_________ AGE:_________ SCHOOL/GRADE:_______________________________POSITION:____________________ HS COACH:______________________________ INDOOR TEAM:_____________________ How did you hear about us:_____________________________________________________ Amount Enclosed: The following questions are designed to help us understand your goals. What are your strongest assets as a player?________________________________________ What do you hope to learn at the clinic? ________________________________________________ Are you interested in playing beyond high school, and if so, where are you looking? ________ ___________________________________________________________________________ What contact, if any, have you had with colleges?__________________________________ Release of Liability and Photo Consent: I hereby release and discharge Goalkeeping 1-On-1, its agents, employees, staff members, directors, volunteers, and officers from any claims, responsibilities or liabilities for injuries or harm incurred as a result of my participation and/or my child’s participation in training programs. I authorize Goalkeeping 1-On1, its agents, employees, staff members, directors, volunteers, and officers to take whatever action is necessary, in their best judgment, in an emergency and I hereby release discharge Goalkeeping 1-On1, its agents, employees, staff members, directors, volunteers, and officers from any responsibility or liability related thereto. I hereby grant Goalkeeping 1-On1 permission to use my and/or my child’s name, picture or likeness in any printed media or any form of advertisement. I fully renounce any and all claims upon Goalkeeping 1-On1 for reimbursement for use of this material. All athletes are required to sign; parent signature also required for those under 18. Date: ____________ Parent: ________________________________Athlete: ____________________________ |
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Enclose a check with clinic fee to secure a spot for the clinic of your choice. Make checks payable to: Goalkeeping 1-On-1 Mail to: Goalkeeping 1-On-1 P.O. Box 31842 Philadelphia, PA 19104-9971. |