Pipech Elite Winter Goalkeeper Training 2021 Registration Form
Please complete all sections of this registration form in it's entirely truthfully and accurately. Please enter FULL first and last names when entering a person. This form must be completed before the child's participation and must be completed by the parent or legal guardian (age 18 or older) of the participant. All responses on this form will remain confidential (unless for emergency purposes to authorized personnel), and are used for necessary registration requirements and/or in the event of any emergency.
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Email *
Cost $200 (ENCO Players $175) Payment method: *
Date of payment sent/made. Please note that due to limited spots, a completed registration form and payment secure your child's place. Without payment, the spot cannot be reserved. *
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Date of completion by Parent or Guardian *
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Name of Player (Participant) *
Age of Participant *
Date of birth (participant) *
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Session (based on age) *
Name of Individual Completing this Form *
Relationship to Player (Participant) *
Gender of child *
Mailing address *
City, State, Zip *
Current Soccer Club *
Phone #1 (primary contact) *
Phone #2
Second Email: *
Emergency Contact *
Do you have medical coverage for your child? This question must be a YES in order for your child to participate. *
Medical Insurance Provider *
Policy Number *
MEDICAL NEEDS of player. If there are no medical needs, please answer NONE. Make sure to state any and all allergies, recent injuries, if your child carries an epi pen (location of), etc. Be specific and clear: *
Parents must sign below prior to child’s participation in the 2021 Pipech Elite Winter Goalkeeper Training. I hereby certify that the applicant is in good physical condition to participate in the 2021 Pipech Elite Winter Goalkeeper Training. If medical assistance is required for illness or injury while attending the camp, I give permission for such care and I certify I have medical insurance, and that the applicant is covered by our family medical insurance. Robert (Bob) Pipech, his associates, Forks Township, Northampton County, are all NOT responsible legally or financially in any manner, and will not provide any payment or have any responsibility for any medical, dental, hospital, transportation, or laboratory fees due to injury incurred while participating in the 2021 Pipech Winter Goalkeeper Training. I hereby release Bob Pipech and his staff of any and all liability from any type of injury as a result of this training. -------------------------------------------------------------------------------------------------------------------------------For your electronic signature, please type your #FullName#. For example, John Smith would type #John Smith# *
Waiver forms. Two waiver forms will be emailed in December which must be completed before participation. In addition, please read over the safety protocols and refunds policy at https://docs.google.com/document/d/1hkFU345F1yFE0CP3NZlK6dxwcKORsIZ8KdkQ7POSSAk/edit?usp=sharing. If you agree, please select YES. If you do not agree with the terms and conditions, please exit this form and if you submitted payment, you will be issued a refund. *
To confirm you read over the safety protocols and refund policy, please enter the last THREE WORDS at the bottom of the refund policy. Please note: if not correct, you will be contacted and asked to resubmit. *
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