2010 Fall Goalkeeper Academy Form

2010 Fall Goalkeeper Academy at Iron Lakes Sports Club

Hosted by FCLehigh

Directed by Bobby Pipech - Muhlenberg College Goalkeeper Coach & Former DI Player at St. Francis University

Boys & girls ages 10 to 18 years
September 10, 17, 24 & October 1, 15, and 22 (6 weeks!)
6 to 7PM
Non-FC Lehigh travel player fee - $120 per player
FC Lehigh travel player fee - Free


*Are you on an FC Lehigh Travel or Academy Team?	Yes No
*Player Name :
*Gender	Male Female
*Age :
*Date of Birth :
	MM/DD/YYYY
Current Soccer Club:
Team Name:
	ie. 97 Girls
*Address
*City
*Zip Code
*Phone # :
	xxx-xxx-xxxx
*Email :
	example@example.com
*Emergency Phone # :
	xxx-xxx-xxxx
*Emergency Contact :
*Name of Medical Insurance Co. :
*Policy No. :
Medical Needs(Please List):
*Parent/Guardian Name :

I hereby certify that the applicant is in good physical condition to participate in the 2010-11 FC Lehigh Academy. If medical assistance is required for illness or injury while attending the Academy, I give permission for such care and I certify that the applicant is covered by our family medical insurance. FC Lehigh & Iron Lakes Staff are not responsible for and will not provide payment of any medical, dental, hospital, transportation, or laboratory fees due to injury incurred while participating in the 2010-11 FC Lehigh Academy.

*Required Fields