716-860-2528

Goaltending School: OnLine Registration Form

Please fill out this form on your computer. Then send the form electronically by clicking the 'send' button, and mail in your check to the address at the bottom of this page.

Gardner Goaltending — 2010

Name:
Street Address:
Town:
State:
  Zip:
Phone #:
E-mail:
Birthdate:
   Gender:

Height:
Weight:
Health Ins. Co.:
Insurance ID #:
Medical Doctor:
Dr.'s Phone #:
Jersey size (pick 1):
Adult:
# years a Goalie:
Choose a week:
Goalie Camp Week, August 2nd - August 6th 2010 ($375 U.S.)     
Future Prospects Week, August 16th - 20, 2010 ($515 U.S.)
Total Fees:
$   Amount sent in now (U.S. funds): $ (either a $195 deposit or the full week's amount)

Consent & Waiver of Responsibility
Please Read Before Signing

I agree that the Gardner Goaltending Institute and/or its propretors will not be held responsible for any accidents or loss however caused, and agree to release the proprietors from clains or damages which may arise as a result of/or by reason of such accidents or loss. Gardner Goaltending Institute reserves the right to use any pictures/video taken during the school for advertising and /or instructional purposes. It is further agreed that Gardner Goaltending Institute is not responsible for lost or stolen personal articles or hockey equipment.

Emergency Contact Name:
Comments/ questions:
Phone #:
Signature of Parent/Guardian (Type in your name and the last 4 digits of your credit card (for ID purposes only to act as a 'digital signature'.)
Parent/Guardian Signature:
Date:
 

Please mail a $195 deposit or the total fee. The balance of the fees must be paid in full 30 days prior to the beginning of the school session or the the spot CAN BE FORFEITED . This application must be signed by a parent or guardian. . Checks should be made payable to "Greg Gardner".

Please mail payment to: Gardner Goaltending, c/o Greg Gardner, Dwyer Arena Hockey Office, Niagara University, NY 14109
 

 

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