RGA Event Registration p.1

Event Registration

Summer 2010 - Hardees Ice Plex Camp 3

Modern Tech Skill Builder; 5 days; 7.5 hrs on-ice instruction; Mite Squirt Peewee Bantam Midget High School

2010-07-26 to 2010-07-30 at Hardee's Iceplex (MO)

Group 1: 12:10pm - 3:40pm; Group 2: 1:50pm - 5:20pm; Camp will have off ice warm up and post ice workouts.

$375.00

Player Info Last Name, First Name, MI: , * Date of Birth: (MM-DD-YYYY) - - * Gender: * Jersey size: * T-shirt size: * Level: * Club Name
Team Name

Parent Info*

Last Name, First Name, MI:,

Street Address
Address continued

CityState Zip

Phone No. Evening: - -

Phone No. Daytime: - -

Email Address

Emergency Contact Info Last Name, First Name, MI:, *

Emergency Phone No.: - - *

Medical Insurance: *

Policy #: *

Medical Concerns:

Survey Questions What is your preferred rink? How did you hear about this event?

Release of Liability* Read the statement below carefully, then check the box.

INSURANCE/MEDICAL: Each Participant should have their own medical insurance. Neither Bruce Racine, Racine Goalie Academy nor anyone associated with Bruce Racine and Racine Goalie Academy will be responsible for any medical or dental insurance considerations.

WAIVER: In consideration of your accepting my child's entry into this program, I hereby waive and release any and all rights and claims for damages I may have against Bruce Racine, Racine Goalie Academy and its personnel for any and all injuries suffered during this clinic.

Liability release, READ and UNDERSTOOD.