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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:____________
HS COACH:______________________________ INDOOR TEAM:_____________________
YOUR ADDRESS: _________________________CITY: ____________ STATE:____ ZIP:________
YOUR PHONE:______________________ E-MAIL:_______________________________________
EMERGENCY CONTACT: ______________________________ RELATION:_____________††† ††††††††††
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.
Name of Participant: _________________________________
Participant DOB: _____________________
Name of Parent/Responsible Adult:_____________________________________________________
Signature of Parent/Responsible Adult: _________________________________________________
Home Phone #: _________________________
Emergency Contact Phone#: __________________________