Grand Rapids Goalie Camp - 2010 Registration Form


Schedule Register GOALCREASE
Grand Rapids, Minnesota
August 8-11, 2010


Level Played in 2009-2010 ______________

Name _________________________________________________________
Address _______________________________________________________
______________________________________________________________
Birth Date _____ / _____ / ______
Parents / Guardians ______________________________________________
Phone: Day_____________ Night____________ Emergency____________
Email Address __________________________________________________

Please Note: This form, as well as the Medical History Form and the Consent To Treat Form, must ALL be printed out, completed, and sent into the address below.

Cost of camp is $430. All applications must include a $300 deposit, refundable only with medical verification. Must be prior to May 31, 2010.

Parent release and indemnity agreement:
To the IRA Civic Center Summer Hockey School: I/We hereby release the City of Grand Rapids, its employees, and the Grand Rapids Hockey Camps instructors from all claims on account of any injuries which may be sustained by my/our child while participating in activities at the IRA Civic Center. I/We agree to indemnify the City of Grand Rapids, its employees, and the Grand Rapids Hockey Camps instructors for each claim which may hereafter be presented by my/our child as a result of injury. I/We also certify that my/our child is medically fit to participate in the Grand Rapids Hockey Camps program.

Parent Signature _____________________________ Email Address ___________________________
Date ____ /____ /_______
Mail to:
IRA Civic Center
420 N. Pokegama Ave.
Grand Rapids, Minnesota
55744

For More Information:
Contact Dale Anderson or Sara Holum at 218.326.2500
Email: danderson@ci.grand-rapids.mn.us