2018 Blockstar Goalie Only Training

Athlete Information

Athlete's Name*

First NameLast Name

Training Attending*

Ideal Date and Time for Training

Athlete's Email:*

example@example.com

Hometown*

State / Province*

Grade*

Age*

Date of Birth*

School*

High School Grad Year*

Club Team (if applicable)

Skill Level

# of Years You Have Played Goalkeeper*

Skills You Wish To Learn/ Work on*

Any field hockey goals you would like to share with us? ie. make varsity, play in college, make national team, etc.

How did you hear about Blockstar?*

Additional Comments/ Questions:

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

Area CodePhone Number

Home Number

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the athlete prescribed an inhaler? If yes, please explain any instructions.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Blockstar Field Hockey during the selected training. In exchange for the acceptance of said child’s candidacy by Blockstar Field Hockey, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Blockstar Field Hockey and all its respective coaches, officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Blockstar Field Hockey including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including field hockey. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Blockstar Field Hockey and its affiliates including Directors, Coaches, and Venue Staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates of the camp attending.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Payment

Since space is limited, please allow 1-2 business days for an email confirmation to confirm your spot in the training. Payment options will be sent in the confirmation email, including the option to set up a payment plan. Our aim is to make the training available and affordable to all so we will work with any budget.

Cancellation Policy:

If you need to cancel a registration, please let us know as soon as possible. We will do our best to fill your spot. Spots are very limited to ensure quality. Once a training is full we will close registration. Once your space is confirmed, a non refundable deposit will be due to hold your spot. You can also pay in full if you prefer. Refunds will only be issued if we are able to fill your spot. If you know a keeper who can take your spot, we will refund you in full.

Thank you for your understanding.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature (typed)*

Blockstar Field Hockey Registration