DOMINATE the 18 Summer Goalkeeper Training 2022 Registration Form - Monday through Friday 8:00 AM to 11:30 AM.  June 20th to 24th (5 days).  
Please complete all sections of this registration form in it's entirely truthfully and accurately. Please enter FULL first and last names when entering a person. This form must be completed before the child's participation and must be completed by the parent or legal guardian (age 18 or older) of the participant. All responses on this form will remain confidential (unless for emergency purposes to authorized personnel), and are used for necessary registration requirements and/or in the event of any emergency.

We will be adhering to all current and updated State, local, and CDC Guidelines for this camp as of June 2022.  If you do not wish for your child to follow these guidelines, we kindly ask that you do not sign up for this camp.

Camp will be held at the Plainfield Township Community Park in Kesslersville, PA. Cost is $305.  
Over 17 hours of Outstanding Goalkeeper Training!

All Goalkeepers will receive a FREE DOMINATE the 18 Goalkeeper and Soccer Training Tshirt!  

Please note that payment for this camp cannot be claimed through FSA or childcare for tax purposes. Thank you.
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Email *
Cost $305. Please note that you will have to manually enter the amount on one of the payment methods below.  Registration is not complete until payment is received.  Please note payment for "Summer GK 2022." in the notation of the payment.   *
Date of completion by Parent or Guardian *
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Name of Player (Participant) *
Age of Participant *
Name of Individual Completing this Form *
Relationship to Player (Participant) *
Date of birth (participant) *
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Gender of child *
Mailing address *
City, State, Zip *
Current Soccer Club *
Phone #1 (primary contact) *
Phone #2
Email: *
Emergency Contact *
Do you have medical coverage for your child? This question must be a YES in order for your child to participate. *
Medical Insurance Provider *
Policy Number *
MEDICAL NEEDS of player. If there are no medical needs, please answer NONE.  Make sure to state any and all allergies, recent injuries, if your child carries an epi pen (location of), etc.  Be specific and clear: *
Parents must sign below prior to child’s participation in the 2022 Dominate the 18 Summer Goalkeeper Training. I hereby certify that the applicant is in good physical condition to participate in the 2022 Dominate the 18 Summer Goalkeeper Training. If medical assistance is required for illness or injury while attending the camp, I give permission for such care and I certify I have medical insurance, and that the applicant is covered by our family medical insurance. Robert (Bob) Pipech, his associates, Plainfield Township, Northampton County, and any associated entities are all NOT responsible legally or financially in any manner, and will not provide any payment or have any responsibility for any medical, dental, hospital, transportation, or laboratory fees due to injury incurred while participating in the 2022 Dominate the 18 Summer Goalkeeper Training.  I hereby release Bob Pipech and his staff of any and all liability from any type of injury as a result of this training.                                                                                                 -------------------------------------------------------------------------------------------------------------------------------For your electronic signature, please type your FULL NAME followed by YOUR First and Last Initials, then #                                                                                                                                                                                 --------------------------For example: Person is John Smith.                           Enter:  John Smith  JS# *
Date of payment sent/made (As accurate as possible/but does not have to be perfect). Please note again that you must enter the amount ($305) on Paypal or Venmo to complete payment, as it will not automatically generate. *
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Waiver form, please go to:  https://www.waiverfile.com/b/PipechElitelSoccerTraining/Waiver.aspx?formid=97761d4c-ba72-4043-a0a0-65ca40a9fac7.  After completing (keep this window open), please confirm below. *
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