Junior Goalie Camp

I HEREBY REGISTER FOR YOUR

Advanced and Performance Camp, Thursday August 1st - Sunday August 4th 2019, 8.00 am - 6.00 pm (detailed schedule on request or by registration) at The Rinks, Yorba Linda, California.

Price: USD 660.00 incl. TAX.

Bantam, Midget, High School, Junior, College - AA, AAA and higher

Single-line Text

ATHLETE INFORMATION

First Name

Last Name

Gender

Date of Birth (Month/Day/Year)

Team/Level

Height (ft/inch)

Weight (lbs)

Glove Side

Jersey Size

Food Preference

ATHLETE CONTACT INFORMATION

Street

ZIP Code

City

State

Country

Phone

Email

FOR ATHLETS UNDER 18 YEARS: PARENTS/GUARDIANS INFORMATION

Name and Address

Phone

Email

HEALTH INFORMATION

All medical information stay confident and only serve appropriate treatment in case of emergency during the program activity.

Health Insurance Carrier

Policy Number

Does participant have allergic reactions to:

Penicillin

Other Antibiotics

Other Medicine (type)

Insect Bites/Stings

Food Products

None of it

If yes, please specify your allergies (e.g. which medicines, products, insects?).

Has the participant had or is he presently experiencing:

Asthma

Diabetes

Epilepsy/Seizures/Blackouts

Heart Disease

Joint Injury/Surgery

Neck/Back Pain/Injury

Major surgery/hospitalization

Other necessary health information or conditions requiring special considerations?

None of it

If yes, please specify.

By submitting this registration form you give your consent in advance for medical treatment at an appropriate medical facility in case of illness or injury during the program activity. You are stating that you are aware of and accept the risk inherent in the program activity, hold harmless and indemnify Sport Action Inc. & Goalie Action and it’s employees from any and all liability, loss, damages, or expenses which are sustained, or required arising out of the actions of your dependent in the course of this camp or clinic.

PAYMENT INFORMATION

Payment preference

Credit Card information (if preferred payment method):

Name on Credit Card

Card No.

Exp. Date

CCV No.

ZIP Code

Almost done! Please let us know where you heard about our camps:

Worked with Goalie Action before

Facebook Goalie Action

Referral

Flyer

California Rubber Magazine

Search Engine

Website

Other

Details on Referral, Search etc.:

Discount Code:

Ready for sending! We will answer your registration within the next couple of days. The participation is only confirmed with the reception of your payment. Thank you for choosing Goalie Action. We are looking forward to a great camp experience with you.

Camp Registration

2019

California, USA: 4 Days Advanced and performance camp