Pipech Elite Summer Goalkeeper Training 2020 Registration Form -June 22nd-26th,9 AM- 12 PM
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.
Email address *
Cost $265 *
Date of completion by Parent or Guardian *
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Name of Player (Participant) *
Your answer
Age of Participant *
Your answer
Name of Individual Completing this Form *
Your answer
Relationship to Player (Participant) *
Your answer
Date of birth (participant) *
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Estimated Glove Size: Each Participant gets a FREE pair of Fingerprotective gloves (over $100 value!) Please use the following link as a guide: https://docs.google.com/document/d/1XE5TcWSOJRsLF5iSoxSg5o8hVwahSZg_xvK9mvpF3xQ/edit?usp=sharing *
Gender of child *
Mailing address *
Your answer
City, State, Zip *
Your answer
Current Soccer Club *
Your answer
Phone #1 (primary contact) *
Your answer
Phone #2
Your answer
Email: *
Your answer
Emergency Contact *
Your answer
Do you have medical coverage for your child? This question must be a YES in order for your child to participate. *
Medical Insurance Provider *
Your answer
Policy Number *
Your answer
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: *
Your answer
Parents must sign below prior to child’s participation in the 2020 Pipech Elite Summer Goalkeeper Training. I hereby certify that the applicant is in good physical condition to participate in the 2020 Pipech Elite Summer 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, Plainfield Township, Northampton County, and any associated entities 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 2020 Pipech Summer 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 FULL NAME followed by YOUR First and Last Initials, then # --------------------------For example: Person is John Smith. Enter: John Smith JS# *
Your answer
Date of payment sent/made (As accurate as possible/but does not have to be perfect) *
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