 Shot Stoppers Goalie School Holiday Field Hockey Goalie Clinic Application |
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| Print this application and send it and a check for $200 made payable to John Kovach to: | |
| Shot Stoppers Goalie School 18501 Mink Hollow Road PO Box 97 Ashton, MD 20861 |
Plan to attend (check one): December
26, 9 AM until 4 PM atVilla Julie College Athletic Facility 10945 Boulevard Circle Owings Mills, MD 21117 $200 Athletic shoes, NOT cleats, should be worn. |
| Applications for Holiday Field Hockey
Goalie Clinic must include full payment. A receipt and more information
will be sent after payment is received. Goalies are responsible for bringing their own equipment. All goalies should bring their own water bottle. Directions to Villa Julie College (http://www.vjc.edu/explore/locations/directions/index.asp) |
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| Name of Camper ______________________________________ |
| Age _____ Date of Birth _________ |
| Email Address: ____________________________ Years Playing Hockey: ______ |
| Street Address _______________________________________ |
| City __________________________________________ |
| State ______________ Zip Code _________ |
| Telephone (_____)___________________ |
| Parent(s) Name ____________________________________________ |
| Name of School _______________________ Grade for Sept. 2007 ___________ |
| 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, 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 Carroll Indoor Sports Center. I hereby give the Interstate Field Hockey Camp permission to have my child treated in case of any emergency.
Signature ________________________________ Date ________________