Goaltending School: OnLine Registration Form 2010

Please fill out this form on your computer. Then click the 'Print' button at the bottom of this page to print out the form on you computer printer.Mail the printed and signed form with your check ($195 deposit or the full amount of the week) to the address at the bottom of this page.

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 - 6th ($375)      Future Prospects Week, August 16th - 20th ($515)
Total Fees:
 $     Amount sent in now (U.S. funds): $


Consent & Waiver of Responsibility: Please Read Before Signing

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. This application must be signed by a parent or guardian. If you are submitting this form electronically, type your name (parent or guardian) . Checks should be made payable to "GREG GARDNER".

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:
Phone #:
Signature of Parent/Guardian (sign in ink after you have printed out this form)
Parent/Guardian Signature:


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