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CLINIC REGISTRATION FORM

Instructions: Please fill out all information requested so we can maximize your experience. Enclose a check with clinic fee to secure a spot for the clinic of your choice. Make checks payable to: Goalkeeping 1-On-1, LLC

 

Mail to: Goalkeeping 1-On-1, LLC

†††††††††††† P.O. Box 31842

†††††††††††† Philadelphia, PA 19104-9971

 

 

NAME:_____________________________________________ CLINIC DATE:____________

 

DOB:_________ AGE:_________

 

SCHOOL/GRADE:_______________________________POSITION:____________________

 

HS COACH:______________________________ INDOOR TEAM:_____________________

 

YOUR ADDRESS: _________________________CITY: ____________ STATE:____ ZIP:________

 

YOUR PHONE:______________________ E-MAIL:_______________________________________

 

EMERGENCY CONTACT: ______________________________ RELATION:_____________††† ††††††††††

 

EMERGENCY CELLPHONE:____________

 

NAME OF INSURANCE COMPANY:________________________

POLICYHOLDER NAME:†††††††††† †††††††††† †††††††††† ††††††††††

INSURANCE GROUP #†† †††††††††† †††††††††† ID#†††††† ††††††††††

 

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?__________________________________

 

 

GOALKEEPING 1-ON-1, LLC RELEASE & ASSUMPTION OF RISK

 

 

In consideration of participating in activities and programs of Goalkeeping 1-On-1, LLC, by and through its members, agents, servants and employees (the Provider), I, for myself, or as a parent, legal guardian and/or adult responsible for the minor (the Participant) listed below, do hereby agree as follows:

 

I waive, release, discharge and agree to indemnify the Provider from any and all claims, losses, demands, damages or liabilities for injuries or harm incurred as a result of the Participantís participation in any Provider authorized activity.

 

I understand that participation in the Providerís activities is strictly voluntary. I understand that participation in the Providerís activities involve a risk of injury and Participant assumes the risk of any harm or injuries, known or unknown, caused by such participation, whether resulting from the actions of the Participant or the actions and inactions of others, included the Provider.

 

I authorize the Provider to take appropriate medical action in the event of accident, illness or injury during Participantís participation in any Provider authorized activity. I further declare that the Participant is covered under a medial insurance policy and understand I will be responsible for any and all medical costs necessary and hereby discharge the Provider from any responsibility or liability related thereto.

 

I give permission to Provider to freely use the Participantís name and/or picture and/or video and/or likeness in any broadcast, telecast, media account or in any advertisement or in any other record for legitimate use.

 

I agree that he laws of the Commonwealth of Pennsylvania shall apply to the interpretation of this Release and any disputes regarding the same shall be resolved by arbitration in Philadelphia County, Pennsylvania.

 

 

I HAVE READ THIS RELEASE AND ASSUMPTION OF RISK, FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS ON BEHALF OF MYSELF, AS WELL AS ON BEHALF OF ANY PARTICIPANT FOR WHOM I AM RESPONSIBLE. I HAVE SIGNED THIS RELEASE FREELY AND WITHOUT INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ANY AND ALL LIABILITY, OF ANY NATURE OR KIND.

 

Date: _____________________________________

 

Name of Participant: _________________________________

 

Participant DOB: _____________________

 

Name of Parent/Responsible Adult:_____________________________________________________

 

Signature of Parent/Responsible Adult: _________________________________________________

 

Address: __________________________________________________________________________

 

Home Phone #: _________________________

 

Emergency Contact Phone#: __________________________