Willmar MN, Youth GOAL SCORING CAMP

Camper Information

First Name

Last Name

Date of Birth

Age (at camp start)

Gender

Male
Female
Prefer not to say
Other

Parent / Guardian Information

Parent/Guardian

Relationship to Camper

Primary Phone

Email (for confirmations/updates)

Level of Play (current)

Medical Information

Family Doctor

Phone

Medical Conditions, Allergies, or Injuries the staff should know about

Medications camper will bring/take at camp (if any)

Does camper carry an inhaler or EpiPen?

If yes, explain (optional)

Health Insurance Company

Policy/Member# (optional)

I authorize Brieres Goalie School staff to arrange emergency medical treatment for my child if necessary.

Parent/Guardian Initials

I have read and agree to the Refund & Cancellation Policy.

I have read and agree to the Privacy Policy.

I have read and agree to the Terms of Service.

I have read and agree to the Liability Waiver & Release of Claims

Code of Conduct

I understand that my child is expected to follow directions of coaches and staff, show respect toward others, and maintain appropriate behavior on and off the ice. Brieres Goalie School reserves the right to dismiss any participant whose behavior is detrimental to the camp, without refund.

Media & Photo Release

I DO (optional)

I DO NOT grant permission for Brieres Goalie School to use photographs or video of my child for promotional purposes (website, social media, flyers, etc.), without compensation. (optional)

Acknowledgment & Signature

I have read, understand, and agree to all information and policies contained in this registration form.

Parent/Guardian Name (print)

Signature (Type Below)

Date

How did you hear about Brieres Goalie School?

Friend/Teammate (optional)

Coach (optional)

Social Media (optional)

Website (optional)

Rink/Flyer (optional)

Email (optional)

Other (optional)