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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 Participant’s participation in any Provider authorized activity. I understand that participation in the Provider’s activities is strictly voluntary. I understand that participation in the Provider’s 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 Participant’s 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 Participant’s 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#: __________________________ |
