 Shot
Stoppers Goalie School Application |
|
| Print this application and sent it and a check made payable to Interstate Field Hockey Camp to: | |
| Shot Stoppers Goalie School 18501 Mink Hollow Road PO Box 97 Ashton, Maryland 20861 All sessions will be held at Ocelot Turf Field, Ashton, MD |
Plan to attend (check one): Session 1 July
7-9 - $400 Session 2 July
10-12 - $400 Elite Session 3 July
14-16 - $400 Elite Session 4 July
17-19 - $400 Session 5 August
4-6 - $400
|
| Applications for Shot Stoppers must include full payment. A receipt and more information will be sent after payment is received. | |
| Name of Camper______________________________________ |
| Age_____ Date of Birth_________ T Shirt Size (Circle One) Small Medium Large X-large |
| Email Address:____________________________ Years Playing Hockey:______ |
| Street Address_______________________________________ |
| City__________________________________________ |
| State______________ Zip Code_________ |
| Telephone_(_____)___________________ |
| Parent(s) Name____________________________________________ |
| Name of School_______________________ Grade for Sept. 2008___________ |
| Medical and Insurance Information |
| Emergency Phone Number(s)_____________________ |
| Parents Insurance Carrier______________________Policy Number______________ |
| Allergies or special medication (attach extra sheets if needed) _____________________________________________________ |
Waiver of Liability (must be signed by parent)
I hereby agree to waive my rights to bring any action
for injury or property damage to my son or daughter against Interstate Field
Hockey Camp or Carroll Indoor Sports Center, their officers, directors, employees
or coaches arising out of his/her participation in field hockey or any other
activities at the camp. I further agree to indemnify and hold harmless the Interstate Field Hockey Camp, Carroll Indoor Sports Center, The Blast Sports Arena or the Mater Amoris Montessori School, its directors,
employees and coaches against all suits, liabilities, claims, demands, fines
and legal actions of any kind or any nature arising from my son's/daughter's
activities and participation in field hockey or any other activities at the
Interstate Field Hockey Camp, Carroll Indoor Sports Center, The Blast Sports
Arena or the Mater Amoris Montessori School. I hereby give the Interstate
Field Hockey Camp permission to have my child treated in case of any emergency.
Signature________________________________ Date________________