DLVG 2019 Summer Goalie Camp

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Registration for the 2019 Summer Goalie Camp

Email *

Goalie's Name *

Date of Birth *

YYYY

Division *

Novice

Atom

Peewee

Bantam

Midget

Other:

Preferred Phone Number *

Medical Information (Allergies, disorders etc) *

Method of Payment *

Cash

Cheque

E-transfer

Credit Card (Enter CC information below if applicable. NOTE - a 3% administration charge will be applied to all CC payments)

Credit Card Info (Number, Expiry Date, 3-digit Security Code & Postal Code)

Jersey Size (Adult Men's) *

XXL

T-Shirt Size (Adult Men's) *

I understand that spaces are limited, and that if I do not abide by the outlined deposit and payment schedule that I risk losing my spot in the program *

YES

I consent to the use of my name, portrait, picture, photograph or video as part of Dan LaCosta's Varsity Goaltending Inc. promotional and teaching materials. (Website, Facebook, Twitter, Email, YouTube, Instagram etc.) *

Yes

I/we do hereby release Dan LaCosta’s Varsity Goaltending Inc. from all liability, claims, or causes of action of any kind whatsoever for any injury, property loss or damages resulting directly, or indirectly from my (child's) participation in this goaltending school, whether incurred on the ice, or otherwise in or about the buildings at the program location or those used by the school at any location or during travel to or from any location, and I/we hereby discharge Dan LaCosta’s Varsity Goaltending Inc. from any, and all future actions, claims and demands. *

YES

A copy of your responses will be emailed to the address you provided.

Submit

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