Dominate the 18 Winter Goalkeeper Training 2022 Registration! Starting January 9th, 2022
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.

Please make sure to carefully read all terms and conditions in the registration form.

We will be adhering to all current and updated State, local, and CDC Guidelines for this training as of December 2021. If you do not wish for your child to follow these guidelines, we kindly ask that you do not sign up for this camp.

PLEASE READ CAREFULLY
The cost for Winter GK is $245. This includes 10 sessions (weather permitting), and a Free T-shirt!

Sessions will be held on Sunday nights from 6 to 8 PM.
U12 and younger: 6 PM to 7 PM
U13 and older: 7 PM to 8 PM

All items must be completed to reserve your child's spot:
1) This registration form
2) Payment (payment links in this form)
3) Waiver (linked at the end of this form).

If one of these items is not completed, the spot cannot be reserved. Please make sure to complete all 3 items. If you wish to verify or have any questions, please email pipechkelmegk@yahoo.com.

Weather is beyond the organizer's control. While every effort will be made to reschedule sessions missed due to inclement weather, this cannot be guaranteed.
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Email *
Cost $245 for 10 sessions (weather permitting). Please note that you will have to manually enter the amount on one of the payment methods below. Registration is not complete until payment is received. Please note payment for "Winter GK 2022." in the notation of the payment. *
Date of completion by Parent or Guardian *
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Name of Player (Participant) *
Age of Participant *
Name of Individual Completing this Form *
Relationship to Player (Participant) *
Date of birth (participant) *
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Gender of child *
Mailing address *
City, State, Zip *
Current Soccer Club *
Phone #1 (primary contact) *
Phone #2
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 2022 Dominate the 18 Goalkeeper and Soccer Training Winter Goalkeeper Training. I hereby certify that the applicant is in good physical condition to participate in the Dominate the 18 Goalkeeper and Soccer Training Winter Goalkeeper Training. If medical assistance is required for illness or injury while attending the training, 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 Pipech, his associates, Test your Mental Fitness & Sports Performance, Forks 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 Dominate the 18 Goalkeeper and Soccer Training Winter Goalkeeper Training. I hereby release Robert 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# *
Confirmation that payment was made. Please note that if you completed this registration form, but did not complete payment, your child's place cannot be reserved until payment is complete. The program usually sells out quickly. If you did not use the Paypal buttons in the middle of the GK Winter webpage for payment, you must manually enter the amount ($245) on the platform used. *
Waiver form, please go to: https://www.waiverfile.com/b/PipechElitelSoccerTraining/Waiver.aspx?formid=9eb89e59-f416-42cf-b858-68265dcf801c . After completing (keep this window open), please confirm below. *
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